nicola brame primary supervisor: professor david peck · aim this study undertook a preliminary...
TRANSCRIPT
Doctoral Thesis
Stress, appraisals, and well-being of staff working with adults with intellectual disabilities
and challenging behaviour
Nicola Brame
Primary supervisor: Professor David Peck
Submission Date: 2nd
June 2014
Word Count = 30,750
Thesis submitted in part fulfilment of the degree of
Doctoral Programme in Clinical Psychology
University of East Anglia
© This copy of the thesis has been supplied on condition that anyone who consults it is
understood to recognise that its copyright rests with the author and that use of any
information derived there from must be in accordance with current UK Copyright Law.
In addition, any quotation or extract must include full attribution.
i
Abstract
Aim This study undertook a preliminary investigation of the staff well-being model with
support staff working with adults with intellectual disabilities and challenging behaviour. The
staff well-being model was conceptualised from Lawton et al.’s (1991) two-factor model of
caregiving appraisal and psychological well-being, Lazarus and Folkman’s (1984)
transactional model of stress, and research literature investigating staff stress and burnout.
The proposed staff well-being model was used to explore hypothesised relationships between
staff stressors, resources, appraisals, and outcome.
Method A cross-sectional online survey was completed by 47 support staff working in
intellectual disability community services, with non-parametric tests of means and
correlational analysis undertaken to explore nine relationships. Appraisals of emotional
exhaustion and personal accomplishment, measured by the Maslach Burnout Inventory, were
compared with staff perceptions of intellectual disability, challenging behaviour, and
organisational demands (stressors), organisational support, social support, wishful thinking,
and practical coping (resources), positive feelings and negative feelings (outcomes).
Results Five significant relationships were found (p < .001). Appraisals of emotional
exhaustion were positively associated with organisational demands, wishful thinking coping,
and negative feelings, and negatively associated with organisational support. Appraisals of
personal accomplishment were positively associated with positive feelings.
Conclusions This preliminary exploration of the staff well-being model found five
significant relationships between staff stressors, resources, appraisals and outcome. The
results are discussed in light of the methodological limitations of this study including the
ii
small sample size, multiple comparisons and correlational design. Further exploration of the
model is suggested in light of its explicit conceptualisation from theories of stress, appraisal
and well-being, with the potential for structural equation modelling to be undertaken with a
larger sample.
iii
Acknowledgements
Firstly, I would like to thank the people, services, and organisations who took part in
this research study, I’m grateful for your interest and enthusiasm. Likewise thank you to
everyone who helped me to advertise this study, especially my fellow trainees.
Special thanks go to my primary supervisor Professor David Peck for your knowledge
and guidance. I have appreciated your patience and positive attitude. Thank you to Dr Pete
Langdon for your support and vital contribution to my online advertising campaign, and Dr
Lynne Roper for your supervision.
Thank you to my friends and family for your unwavering support and humour.
Especially Karina, for everything you are, and my parents, brothers and sisters for your
constant love, comfort, and encouragement. A shout out to Frances for keeping me motivated
during our many hours in ‘Hel’ and Liam for helping me to escape.
Finally, I would like to dedicate this thesis to the memory of my friend Danny
Lynham (1982-2012), a real scientist who affectionately teased me and sadly won’t get to see
me finally finish being a student.
iv
Contents
Abstract…………………………………………………………………………. i
Acknowledgements…………………………………………………………....... iii
List of Tables…………………………………………………………………... x
List of Figures…………………………………………………………………... xi
Chapter 1: Introduction………………………………………………………... 1
1.1. Chapter Introduction………………………………………………………... 1
1.2. The Role of Clinical Psychologists in Intellectual Disability Services…….. 1
1.3. Adults with Intellectual Disabilities and Challenging Behaviour………….. 3
1.3.1. Historical perspective on intellectual disability and community
services……………………………………………………………….. 3
1.3.2. Intellectual disability…………………………………………………. 5
1.3.3. Challenging behaviour………………………………………………... 6
1.3.4. Intellectual disability social care provision............................................ 7
1.4. Supporting Adults with Intellectual Disabilities in Community Services….. 8
1.4.1. The role of staff who support adults with intellectual disabilities……. 8
1.4.2. Research conducted with support staff……………………………….. 9
1.5. Stress………................................................................................................... 11
1.5.1. Models of work stress used to understand staff stress……………….. 13
1.5.1.1. Personal environment…………………………………………… 13
1.5.1.2. Demand-support………………………………………………… 13
1.5.1.3. Cognitive behavioural…………………………………………… 14
1.5.1.4. Emotional overload……………………………………………... 15
1.5.1.5. Equity…………………………………………………………… 15
v
1.5.1.6. Summary………………………………………………………... 15
1.6. Burnout………............................................................................................... 16
1.6.1. Measuring burnout…………................................................................ 17
1.6.2. How does burnout affect intellectual disability staff?.......................... 19
1.6.3. Updating the literature review on intellectual disability staff burnout. 21
1.6.3.1. General characteristics of the studies…………………………… 22
1.6.3.2. Client characteristics…………………………………………..... 31
1.6.3.3. Organisational variables………………………………………… 32
1.6.3.4. Personal and demographic variables……………………………. 33
1.6.3.5. Staff well-being and behaviour…………………………………. 34
1.6.3.6. Intervention and longitudinal studies…………………………… 35
1.6.3.7. Discussion of literature review………………………………..… 38
1.6.4. Summary……………………………………………………………… 40
1.7. A Theoretical Model Investigating both Positive and Negative Aspects of
Caregiving…………………………………………………………………… 41
1.7.1 A two-factor model of caregiving appraisal and psychological well-
being………………………………………………………………….. 42
1.7.2. Testing the two-factor model of caregiving appraisal with familial
caregivers of older people…………………………………………… 44
1.7.3. Use of the two-factor model in other populations…………………… 46
1.8. The Research Study………………………………………………………… 47
1.8.1. Conceptualising the model…………………………………………… 47
1.8.1.1. Stressors………………………………………………………… 47
1.8.1.2. Resources……………………………………………………….. 48
1.8.1.3. Appraisals………………………………………………………. 48
vi
1.8.1.4. Outcomes……………………………………………………….. 48
1.8.2. The staff well-being model…………………………………………... 49
1.8.3. Study aim…………………………………………………………….. 50
1.8.4. Research questions and hypotheses………………………………….. 50
Chapter 2: Method…………………………………………………………….. 52
2.1. Chapter Introduction……………………………………………………….. 52
2.2. Design………………………………………………………………………. 52
2.3. Participants…………………………………………………………………. 52
2.3.1. Power analysis and sample size……………………………………… 52
2.3.2. Inclusion and exclusion criteria……………………………………… 53
2.3.3. Recruitment………………………………………………………….. 53
2.3.3.1. Recruitment through organisations…………………………….. 53
2.3.3.2. Recruitment through online advertisements……………………. 54
2.3.3.3. Response rate……………………………………………………. 55
2.3.4. Sample……………………………………………………………….. 56
2.4. Measures……………………………………………………………………. 57
2.4.1. Internet survey……………………………………………………….. 57
2.4.2. Demographic information……………………………………………. 58
2.4.2.1. Support given to service users…………………………………... 58
2.4.3. Stressors………………………………………………………………. 59
2.4.3.1. Intellectual disability……………………………………………. 59
2.4.3.2. Challenging behaviour………………………………………….. 59
2.4.3.3. Organisational demands………………………………………… 60
2.4.4. Resources…………………………………………………………….. 61
vii
2.4.4.1. Organisational support………………………………………….. 61
2.4.4.2. Social support…………………………………………………… 62
2.4.4.3. Coping mechanisms…………………………………………….. 63
2.4.5. Appraisals…………………………………………………………….. 63
2.4.6. Outcomes……………………………………………………………... 64
2.4.7. Pilot study……………………………………………………………. 65
2.5. Procedure……………………………………………………………………. 66
2.6. Ethical Considerations………………………………………………………. 67
2.6.1. Approval……………………………………………………………… 67
2.6.2. Consent……………………………………………………………….. 67
2.6.3. Confidentiality………………………………………………………... 68
2.6.4. Internet Security………………………………………………………. 69
2.6.5. Debrief………………………………………………………………… 69
Chapter 3: Results………………………………………………………………. 71
3.1. Chapter Introduction………………………………………………………… 71
3.2. Data Analysis………………………………………………………………... 71
3.3. Descriptive Statistics………………………………………………………… 73
3.3.1. Stressors………………………………………………………………. 73
3.3.2. Resources……………………………………………………………... 75
3.3.3. Appraisals…………………………………………………………….. 75
3.3.4. Outcomes……………………………………………………………... 76
3.4. Research Hypotheses……………………………………………………….. 77
3.5. Adjusted p-values for Multiple Tests………………………………………. 78
3.6. Explorative Post-hoc Analysis……………………………………………… 80
viii
3.7. Results Summary…………………………………………………………… 81
Chapter 4: Discussion…………………………………………………………. 82
4.1. Chapter Introduction……………………………………………………….. 82
4.2. Summary of Results………………………………………………………... 82
4.3. Research Questions and Hypotheses………………………………………. 82
4.3.1. Are there associations between stressors and appraisals as
conceptualised in the staff well-being model?…………………………….. 82
4.3.1.1. Hypothesis 1…………………………………………………… 82
4.3.1.2. Hypothesis 2…………………………………………………… 84
4.3.1.3. Hypothesis 3…………………………………………………… 85
4.3.1.4. Discussion of the first research question………………………. 85
4.3.2. Are there associations between resources and appraisals as
conceptualised in the staff well-being model?............................................... 86
4.3.2.1. Hypothesis 4……………………………………………………. 86
4.3.2.2. Hypothesis 5……………………………………………………. 86
4.3.2.3. Hypothesis 6……………………………………………………. 87
4.3.2.4. Hypothesis 7……………………………………………………. 87
4.3.2.5. Discussion of the second research question……………………. 88
4.3.3. Are there associations between appraisals and outcome as
conceptualised in the staff well-being model……………………………… 88
4.3.3.1. Hypothesis 8…………………………………………………… 89
4.3.3.2. Hypothesis 9…………………………………………………… 89
4.3.3.3. Discussion of the third research question……………………… 89
4.4. Strengths and weaknesses of the study……………………………………… 90
4.4.1. Theoretical model……………………………………………………. 90
ix
4.4.2. Use of an internet survey…………………………………………….. 92
4.4.3. Measures……………………………………………………………... 95
4.4.4. Sample……………………………………………………………….. 98
4.4.5. Statistical analysis……………………………………………………. 102
4.5. Implications of the Research Findings……………………………………… 104
4.5.1. Theoretical implications……………………………………………… 104
4.5.2. Clinical implications…………………………………………………. 104
4.5.3. Research Implications……………………………………………….. 106
4.6. Future Research…………………………………………………………….. 106
4.7. Conclusions………………………………………………………………… 107
References………………………………………………………………………. 109
Appendices……………………………………………………………………… 130
x
List of Tables
Table 1.1. Classification of intellectual disability in ICD 10………………………… 6
Table 1.2. Summary of studies included in the systematic review…………………... 25
Table 2.1. Descriptive characteristics of participants………………………………... 56
Table 3.1. Descriptive statistics for the main study variables……………………….. 74
Table 3.2. Holm’s adjusted p-value for multiple tests………………………………. 79
xi
List of Figures
Figure 1.1. Systemic factors for an individual living in an intellectual disability
residential service…………………………………………….................. 2
Figure 1.2. Core constructs of staff research and hypothesised links between them... 10
Figure 1.3. Caregiving model for spouse and adult caregivers…………………….... 45
Figure 1.4. The conceptual staff well-being model and hypothesised relationships.... 49
Figure 4.1. Significant relationships found……………………….…………………. 83
Figure 4.2. Hypothesised relationships not explored in the current study…………… 91
1
Chapter 1: Introduction
1.1. Chapter Introduction
This chapter introduces the reader to what a clinical psychologist might need to know
about the system surrounding an individual with intellectual disabilities and challenging
behaviour supported by a community service. After a brief exploration of historical
perspectives, current definitions of intellectual disability and challenging behaviour are
provided with information about current social care provision. The focus then turns to
exploring the role of support staff and research literature investigating core constructs of staff
who support adults with intellectual disabilities. Current understanding about staff well-being
is provided through a brief description of stress and work stress theory and a systematic
literature review of research conducted into staff burnout. A lack of theory driven hypothesis
testing research in this area is identified and a theoretical model of caregiving appraisal and
psychological well-being used in other populations described. The final section of the chapter
looks at how this theoretical model may be applied to investigate intellectual disability staff
stress, appraisals and well-being.
1.2. The Role of Clinical Psychologists in Intellectual Disability Services
Clinical psychologists undertaking assessment or intervention with individuals with
intellectual disabilities are required to think systemically about all the factors in the
individual’s environment and the interaction between these. As shown in Figure 1.1, a
clinical psychologist would try to understand the individual in their immediate environment,
in this example a residential service. Thinking about the individual’s interactions with staff,
service users, and family, and interrelations between the staff, service users, and family. With
recognition that residential services are commissioned by care managers in local authority
social services, according to Government policy and legislation on social care and influenced
by society and economics.
2
The system must be viewed as a whole, with a problem at one level impacting on
others. It is necessary to understand how an intervention undertaken with an individual must
be considered within the staff team and community service. Furthermore a clinical
psychologist might undertake interventions at the level of the staff team to make sense of or
improve interactions between staff and an individual, or within the staff team and service.
Figure 1.1. Systemic factors for an individual living in a residential service.
This study is focussing on the staff, specifically the psychological well-being of staff
who support adults with intellectual disabilities and challenging behaviour in community
services. Understanding concepts of stress and burnout can help clinical psychologists to
develop and implement interventions to reduce distress. It could be hypothesised that
interventions at this level of the system could improve staff interrelations and interactions
with services users.
Society
Local
Community
Economic
s
Politics
Legal
Health
Social
Values
Residential
Service
Organisation
Local
Healthcare
Local
Authority
Social Care
Other
service
users
Residential
service staff
Family
Individual
Employment
Education
3
1.3. Adults with Intellectual Disabilities and Challenging Behaviour.
The concepts of ‘intellectual disability’ and ‘challenging behaviour’ have developed
over time. Both terms are socially constructed and have changed with society alongside legal,
political and medical perspectives. A brief insight into the history of these terms can aid our
understanding of present day perspectives (for a detailed inspection see Wright & Digby,
1996).
1.3.1. Historical perspective on intellectual disability and community services. In
medieval times the Crown had the responsibility for protecting the person and property of
‘fools’ and ‘idiots,’ who were understood to have irrecoverable conditions that disabled them
from birth (Neugebauer, 1996). Originally linked with profit, the welfare aspect significantly
expanded during the 17th and 18th century through the Poor Law, with parishes paying
relatives or nurse/landlords to care for those described as ‘innocent,’ ‘natural’ and ‘simple’
(Andrews, 1996; Rushton, 1996). In Victorian England there was increasing reference to
scholastic attainment with families conceptualising deficiencies with their children and
attempting to impart basic knowledge and skills (Wright, 1996). Under the Lunatics
Amendment Act the legal definition of ‘insane’ included ‘idiots’ and ‘imbeciles,’ people
could be labelled with Certificates of Insanity, and families sought asylum care due to issues
of poverty (Wright, 1996).
Five voluntary institutions emphasising moral training, task-centred learning, health,
and habits of discipline, were created from the 1840s by the Charity for the Asylum for Idiots
(Gladstone, 1996). By 1881, 3% of the estimated 29,542 ‘idiot’ inmates of institutions were
in special ‘idiot’ asylums, with increasing interest in containment. Concern for the cause and
symptoms of ‘feeble-mindedness’ grew, with perception of ‘mental defectives’ as a burden to
society and a criminal and genetic threat (Jackson, 1996). The 1913 Mental Deficiency Act
4
empowered the state to detain ‘mental defectives’ and economic pressure forced families to
find statutory care through guardianships (Thomson, 1996).
The introduction of the National Health Service in 1948 meant institutions became
hospitals and the detained became ‘patients with health problems’ (Gone, Hatton & Caine,
2012). In the 1950s 60-64,000 people were living in long-stay hospitals (Felce, 1996a), with
100,000 under the care and control of the Mental Deficiency Act (Tredgold, 1952, as cited by
Race, 2002). After eugenic ideas were discredited, The Seebohm Report (Seebohm, 1968)
recommended social services departments were set up in local authorities (Donnison, 1969).
The White Paper, Better services for the mentally handicapped (Department of Health and
Social Security, 1971) subsequently suggested the development of community-based services
(Gone et al., 2012).
Government committees were set up after scandals of institutional abuse and ideas of
‘normalisation’ led to the publication of An Ordinary Life (King’s Fund, 1980) describing
people living in ordinary homes, in ordinary houses, in ordinary streets, and using ordinary
facilities (Thomas & Woods, 2003). Normalisation was the way people were treated, talked
to, called, activities they had access to, and the building people lived in; it was not giving
treatment, trying to change the individuals, or making people normal (Thomas & Woods,
2003). Residential, day and family support services increased through the 1980s and 1990s
(Gone et al., 2012), and the last long-stay ‘mental handicap’ hospital, Orchard Hill, closed in
May 2009 (Sutton Guardian, 2009). The White Papers Valuing People (Department of
Health, 2001) and Valuing People Now (Department of Health, 2009) identified how people
with learning disabilities should have the same rights, choices, dignity, respect, chances,
responsibilities and hopes as everyone else. Community intellectual disability teams were
outlined to provide support to social care providers: to embed principles of personalisation
5
and offer interventions and training with paid and family carers of people with intellectual
disabilities (Department of Health, 2008, 2010).
At present, the review Transforming care: A national response to Winterbourne View
Hospital (Department of Health, 2012) recognises how staff whose job it is to care for and
help people can instead mistreat, neglect and abuse; highlighting continuing weaknesses in
how adults with intellectual disabilities and challenging behaviours are cared for.
1.3.2. Intellectual disability. The World Health Organisation (2010), American
Psychiatric Association (2013) and American Association for Mental Retardation (Luckasson
et al., 2002) specify different diagnostic criteria and classification of intellectual disability
(the term learning disability is used outside of academia). Three core criteria must be met for
a person to be considered to have an intellectual disability: significant impairment of
intellectual functioning, significant impairment of adaptive/social functioning, and age of
onset before adulthood (Ball, Bush & Emerson, 2004).
Level of intellectual functioning is based on the normal distribution of general
intelligence and tested through psychometric assessment. Significant impairment would be
defined as performance on the assessment more than two standard deviations below the
population mean (British Psychological Society, 2000). Level of adaptive/social functioning
impairment is determined through comparison of the person with the standards expected for
the person’s age by cultural group. Included in this comparison are: communication, self-
care, home living, social-interpersonal skills, use of community resources, self-direction,
functional academic skills, work, leisure, and health and safety (American Psychiatric
Association, 2013). Describing limitations within these areas helps to develop a profile of the
support a person might need, with the belief that limitations often coexist with strengths, and
appropriate support over time will improve life functioning (Luckasson et al., 2002). The
International Classification of Diseases-10 (ICD 10, World Health Organisation, 2010)
6
classifies four levels of intellectual disability: Mild, moderate, severe, and profound. These
are shown in Table 1.1 and are classified by intelligence quotient (IQ) and the support an
individual requires.
Table 1.1
Classification of intellectual disability in ICD-10 (World Health Organisation, 2010)
Category of
Intellectual
Disability
Mild Moderate Severe Profound
IQ 50 - 69 35 - 49 20 - 34 Below 20
Support as
adults
Able to work,
maintain good
social
relationships
and contribute to
society
Need varying
degrees of
support to live
in the
community
Likely to result
in continuous
need for support
Severe
limitation in
self-care,
continence,
communication
and mobility
Note: IQ = Intelligence Quotient.
The prevalence of intellectual disability in community populations is between 1% and
3%: with 85% classified as mild, 10% moderate, 3% to 4% severe, and 1% profound
(American Psychiatric Association, 2013). The number of adults with intellectual disabilities
in England was recently estimated as 908,000, with 22% of these known to intellectual
disability services (Emerson et al., 2012). Prevalence rates for mental illness in people with
intellectual disability were found to be higher than the general population at 35.2% to 40.9%
depending on diagnostic criteria (Cooper et al., 2007). The prevalence of challenging
behaviour has been identified as between 6% and 10% (Emerson et al., 2001; Kiernan &
Qureshi, 1993; Lowe et al., 2007).
1.3.3. Challenging behaviour. Challenging behaviours are recognised as behaviours
that challenge services, as opposed to the appearance of psychopathological processes (Felce
& Emerson, 1996). A good definition is:
Behaviour can be described as challenging when it is of such intensity, frequency or
duration as to threaten the quality of life and/or the physical safety of the individual or
others, and is likely to lead to responses that are restrictive, aversive or result in
7
exclusion. (Royal College of Psychiatrists, British Psychological Society, and Royal
College of Speech and Language Therapists, 2007, p. 14).
Challenging behaviour is difficult to define due to the breadth of behaviours that can be
termed challenging. Emerson and Einfield (2011), combined the results of prevalence studies
for challenging behaviours and reported rates of physical aggression at 2.1%, self-injury
1.3%, property destruction 1.3%, and 3.4% for other forms of challenging behaviour. These
other behaviours include generalized noncompliance, temper tantrums, repetitive pestering,
screaming, and stealing. Behaviours termed aggressive include hitting others with hands or
objects, verbal aggression and cruelty. Self-injurious behaviour covers hitting body with hand
or against objects, scratching or pinching self, and hair pulling. A recent total population
screening study found an indication of co-morbid psychiatric disorders in 17% of adults with
intellectual disabilities and challenging behaviour (Allen, Lowe, Matthews, & Anness, 2012).
People with intellectual disabilities showing challenging behaviours have a greater
likelihood of being placed into a residential care service (Hastings, 1997). Staff working with
clients who show challenging behaviour have been found to be more anxious, feel less
supported, to have lower job satisfaction, and report stronger emotional reactions and make
more critical remarks towards clients (Jenkins, Rose & Lovell, 1997; Weigel, Langdon,
Collins & O’Brien., 2006). The quality of support offered in services to people with
challenging behaviour has been described as inadequate, with low levels of staff engagement
and high levels of service user inactivity (Carnaby, Roberts, Lang, & Nielsen, 2010).
Individuals showing challenging behaviours are also at greater risk of abuse by care
givers and are less likely to receive effective psychological support (Emerson, 2001), with
high levels of antipsychotic prescriptions for behavioural problems not related to mental
disorder (Okorie & Connaughton, 2011) and an overreliance on restraint (Jones, 2013).
1.3.4. Intellectual disability social care provision. The majority of adults with
learning disabilities do not use social services (Emerson et al., 2012). Depending on need,
8
local authorities may provide adults with intellectual disabilities with social care packages
including accommodation, community services, home care, and professional support, or they
can provide direct payments and personal budgets. The most common form of
accommodation in 2010/2011 of the 138,995 people with intellectual disabilities known to
local authorities was living permanently with family or friends (29%), followed by registered
care homes (16.9%), supported accommodation/supported group homes (12.7%), and some
form of tenancy (12.5%, Emerson et al., 2011).
In 2011/2012 independent sector residential care was the most common form of
residential support for adults with intellectual disabilities (31,960 adults), with a smaller
number in adult placements (3,960), local authority staffed residential homes (2,315), or
nursing care (2,035, Emerson et al., 2012). Adults with learning disabilities using local
authority community services numbered 113,505, with 51,710 adults using day services.
1.4. Supporting Adults with Intellectual Disabilities in Community Services.
Support staff within community services have a range of responsibilities. Research studies
have been conducted to investigate hypothesised links between staff variables and staff
behaviour.
1.4.1. The role of staff who support adults with intellectual disabilities. Support
staff are responsible for translating national and organisational policies into practical day to
day support for adults with intellectual disabilities. Staff working in community services are
required to support adults with intellectual disabilities depending on their individual care
plan, which details personal needs and wants. This may be with independent living skills of
personal care, administering medication, cooking, cleaning, and undertaking hobbies within
the home, and community activities such as study activities, paid or voluntary work,
entertainment, leisure and shopping. Staff may support one or many individuals at once, and
they may work alone or in large teams undertaking irregular shift patterns over a 24-hour
9
period. Alongside this the staff are required to undertake administrative tasks of record
keeping and report writing, and organisational tasks of health and safety, training, meetings
and supervision.
Windley and Chapman (2010), using a qualitative approach, reported the perceptions
of support workers working with adults with intellectual disabilities. Staff reported wanting
to maximise service user quality of life with access to meaningful activities, improving skill
levels and autonomy. Being caring, empathic and having a good relationship with service
users was considered important for effective support. Role conflict was identified within
teams, with requests for managers to be more proactive, and staff reported stressors of the job
impacting on home life and sense of well-being. Windley and Chapman (2010) highlighted
how support worker skills were often developed through trial and error, and how staff may
not be equipped to explain the reason behind their practice or challenge poor practice.
Training which facilitated personal skill development like assertiveness, communication
skills, stress and time management were felt to be life skills that could be practiced in and
outside of work to enable staff coping strategies to be more effective and transferable
(Windley and Chapman, 2010).
1.4.2. Research conducted with support staff. A diverse range of research has been
conducted with staff supporting adults with intellectual disabilities. The core constructs of
staff research identified by Hatton, Rose and Rose (2004) and some hypothesised links
between them are shown in Figure 1.2. Firstly, it is hypothesised that staff behaviour has a
direct impact on people with intellectual disabilities through interactions between them.
Secondly, it is hypothesised that staff behaviour has an indirect impact on people with
intellectual disabilities through factors like absenteeism and turnover that affect an
organisation’s ability to deliver support packages. Thirdly, it is hypothesised that staff
behaviour is influenced by 1) service user variables of characteristics and behaviour, and the
10
cognitive and emotional staff reactions to these, 2) organisation variables of resources,
support, and salary, and 3) staff variables of skills, values, morale and well-being, and other
characteristics (Hatton et al., 2004).
Figure 1.2. Core constructs of staff research and hypothesised links between them
(Hatton, Rose & Rose, 2004).
Weiner’s (1980, 1985) cognitive (attribution) – emotion – action model of motivated
behaviour has been used extensively to explore staff attributions, emotional reactions, and
propensity to help clients with intellectual disabilities and challenging behaviour (Bailey,
Hare, Hatton, & Limb, 2006; Dagnan, 2012; Hastings, Tombs, Monzani, & Boulton, 2003;
Lucas, Collins, & Langdon, 2009; Noone, Jones, & Hastings, 2006; Stanley & Standen,
2000; Wanless & Jahoda, 2002; Weigel et al., 2006). There is some evidence that training can
lead to change in staff cognitive variables, with a key aspect of this the development of a
formulation of specific client behaviour (Williams, Dagnan, Rodgers, & McDowell, 2012).
Impact on
organisation
Impact on person with
intellectual disabilities
Staff behaviour/
performance
Staff reaction to person
with intellectual disability
Organisational
characteristics
Staff
skills
Staff
values
Staff morale and
well-being
Staff
characteristics
Characteristics of person
with intellectual disability
11
Research literature investigating Weiner’s theory has been described as ‘inconsistent’
and criticised for the varied and limited methodologies used (Willner & Smith, 2008). In
particular, the use of vignette methodology has been criticised, with significant differences
found between staff responses to real and hypothetical scenarios depicting challenging
behaviour (Lucas, Collins, & Langdon, 2009; Wanless & Jahoda, 2002). After reviewing the
literature on attribution theory applied to helping behaviour, Willner and Smith (2008)
advised that alternative theoretical approaches could be used for understanding helping
behaviour through staff coping styles, staff training, job satisfaction and burnout.
The area of focus in this study is the third hypothesised framework for researching
staff behaviour looking at the influence of service user variables, organisational variables,
and staff variables. This study is not intended to directly investigate problem staff behaviour
and its aetiology. The study will instead explore the staff variable of ‘well-being’ through
theories of stress and burnout. In staff research literature the words stress and burnout are
often used in combination without a clear explanation of what the terms represent. Maslach
(1982), a leader in the research of burnout, described burnout as one type of job stress. A
brief description of stress and work stress theory in relation to staff in intellectual disability
services will be given, before a systematic review of the research literature on burnout.
1.5. Stress.
The word stress can be used in a number of different ways. It may signify something
that puts someone under pressure, as in a stressor, seen as a stimulus or input in a particular
situation (Grimshaw, 1999). It can also describe the outcome of that pressure causing us
strain, potentially leading to symptoms of anxiety or low mood. Therefore pressure is normal,
unavoidable, a motivator to get us to complete tasks, learn new skills, seek excitement and
achievement. The pressure though could be too much to manage leading to strain, negative
emotional consequences, and less capacity to complete tasks to the best of our ability.
12
Cordes and Dougherty (1993) cite the work of McGrath (1976) and Schuler (1980) in
their conceptualisation of job stress, and consequently burnout, as a type of stress. Stress is
defined as ‘a dynamic condition in which an individual is confronted with an opportunity,
constraint, or demand on being/having/doing what one desires and for which resolution is
perceived to have uncertainty but which will lead to important outcomes’ Cordes and
Dougherty (1993, pp. 625). Burnout is described as a particular type of job stress in which a
pattern of strains results from a variety of work demands, notably interpersonal stressors
(Cordes and Dougherty, 1993).
The terms stress and burnout are often used interchangeably within intellectual
disability research. Hastings, Horne and Mitchell. (2004) and Skirrow and Hatton (2007)
elaborate suggesting that burnout can be understood as a process in which initial feelings of
stress lead to longer-term feelings of fatigue or exhaustion and finally to attitudinal and
behavioural change. Rose (2009) identified that with staff the wider area of psychological
well-being is usually encompassed within the word ‘stress,’ whilst ‘burnout’ is used to
describe specific outcome measures used in intellectual disability research. Burnout as a
measure supports investigations of the long-term impact of stress on staff as it incorporates
aspects of emotional, behavioural and attitudinal change (Hastings et al., 2004).
Hodgkins, Rose and Rose (2005) provided staff with space to discuss difficulties they
faced in their jobs. Recurring themes across services were: excessive work pressure, demands
of new initiatives and the implementation of person-centred planning, lack of communication
between staff and management, challenging behaviour of some residents, poor support during
and after incidents of challenging behaviour, and relationships between staff and clients’
relatives (Hodgkins et al., 2005). Rose, Jones and Fletcher (1998) report that staff in ‘high
stress’ homes with higher levels of challenging behaviour have fewer positive interactions
with clients than staff in ‘low stress’ homes, though Rose & Rose (2005) found high stress
13
levels were not found to relate to staff thoughts and feelings about propensity to help clients
with challenging behaviours.
It would be interesting to explore how this process of stress, as an input and an output,
has been approached within staff research, and to think about how this might be relevant to a
clinical psychologist working within intellectual disability services. With this in mind the
next section will explore what theoretical models have been put forward to help understand
stress and how it affects staff.
1.5.1. Models of work stress used to understand staff stress. Devereux, Hastings
and Noone., (2009) reviewed work stress theories applied to research staff burnout and found
the research offered only limited support for the predictions derived from those theories.
1.5.1.1. Personal environment. The person-environment theory proposes a
discrepancy between staff needs or abilities and their working environment causing role
overload, role ambiguity and role conflict, leading to burnout. In support of this, Hatton,
Rivers et al. (1999) found that a greater difference between real and ideal organizational
culture was associated with greater job strain, alienation from the organisation, intention to
leave and reduced work satisfaction. Staff experiencing high levels of burnout were found to
be more likely to be absent or leave their employment (Rose, 1995), with Hatton and
Emerson (1998) reporting actual turnover associated with satisfaction with public respect for
the job and practical support from supervisors.
1.5.1.2. Demand-support. The demand-support-constraint model (Payne, 1978, as
cited by Rose, Jones & Fletcher, 1998) proposes there is a greater risk of staff stress when job
demand is high and staff perceive job control and support as low. Rose et al. (1998)
investigated how changing the working environment can have a direct impact on
psychological well-being by conducting focused, assessment-based stress management
programmes. Staff anxiety was found to be significantly reduced in the intervention group
14
compared with the control, but the effect size was not significant through the small sample
size lacking power (Rose et al., 2008).
1.5.1.3. Cognitive behavioural. Staff stress has been examined within cognitive
behavioural theory and the Lazarus and Folkman (1984) model of stress, appraisal and
coping. The theory proposes that the relationship between potential stressors and their
outcome is not direct. Instead, people make primary appraisals about whether the stressful
situation is a threat or a challenge. Appraisals are believed to be influenced by environmental
variables such as demands, constraints, opportunity, and culture, and by personal variables
like goals, beliefs about self and world, and personal resources (Lazurus, 1999). If a person
does not think they have the resources to change the stressful situation they may appraise it to
be a threat, however if the person thinks they have the resources to improve the situation they
may appraise it to be a challenge.
Subsequently secondary appraisals are made.Secondary appraisals are described as a
cognitive-evaluative process that focuses on what can be done to cope with the stressful
person-environment relationship (Lazarus, 1999). People are thought to use different coping
strategies depending on primary appraisals: either problem-focused coping associated with
challenges and positive outcomes, or emotion-focused coping associated with appraisals of
threat and negative outcomes. Stressful situations, appraisals and coping strategies can all
influence one another and change over time, so the process is termed transactional and
dynamic (Lazarus & Folkman, 1984).
Challenging behaviour, the emotional impact of work, conflict of work with personal
or family demands, uncertainty around job tasks and limited opportunities for personal
advancement have all been identified as staff stressors (Hatton, Brown, Caine, & Emerson,
1995). Emotion-focused coping strategies (e.g. wishful thinking) are associated with higher
levels of staff burnout, and have been reported to mediate the relationship between work
15
demands and level of burnout (Hatton et al., 1995; Hatton, Emerson et al., 1999; Mitchell &
Hastings, 2001). Howard, Rose and Levenson (2009) suggested staff’s self-efficacy or
perception of their ability to manage challenging behaviour may mediate between the stressor
and burnout. No difference was found between level of burnout in groups of staff in
residential community settings with low levels of challenging behaviour and staff in secure
settings with high levels of challenging behaviours, but staff in secure settings reported
higher levels of self-efficacy in comparison to community settings (Howard et al., 2009).
1.5.1.4. Emotional overload. Similarly the emotional overload theory suggests job
demands and interpersonal demands of staff-client relationships overload emotional resources
leading to burnout. Associations have been found between job demands of challenging
behaviour and low levels of organisational support with greater emotional reactions and
anxiety (Jenkins et al., 1997; Weigel et al., 2006).
1.5.1.5. Equity. Equity theory and social-exchange theory propose that staff
perception of inequity within staff-client relationships can lead to burnout when staff do not
receive expected rewards compared with the effort they put into the relationship. Schaufeli,
Van dierendonck, and Van Gorp (1996) found that staff who invest more into their
relationship with clients, and their relationship with their organization, than they received
back were more likely to report symptoms of burnout. Disley, Hatton, and Dagnan (2009)
reviewed the intellectual disability staff research literature and found six studies where staff
felt under-benefitted in their relationships with service users, with these perceptions
associated with outcomes of burnout, absenteeism and intention to leave.
1.5.1.6. Summary. Devereux, Hastings and Noone (2009) identify three common
themes through these five work stress theories: jobs exert pressure on workers, workers draw
upon resources to meet the demands, and there is a cognitive process that interacts between
these. Overall intellectual disability research conducted using these five work stress theories
16
have offered limited support, with Devereux, Hastings and Noone (2009) criticising a lack of
clarity about how research questions and hypotheses have been drawn from each theoretical
model. Another criticism was the lack of research into positive outcomes of stressful events
as found by Folkman (1997) with caregivers, with evidence of staff positive perceptions of
intellectual disabilities (Bell & Espie, 2002; Hastings & Horne, 2004) not explored further.
The limited support for these theories hinders the development of clinical interventions to
reduce staff stress and burnout, with future focus directed at interventions directed at the
organisation and support for staff, with potential techniques to enhance psychological
resilience (Devereux, Hastings & Noone, 2009).
1.6. Burnout
Burnout. The word evokes images of a final flickering flame, of a charred and empty
shell, of dying embers and cold, gray ashes…..All of them were once fired up about
their involvement with other people – excited, full of energy, dedicated, willing to
give tremendously of themselves for others. And they did give….and give, and give
until finally there was nothing left to give anymore. The teapot was empty, the battery
was drained, the circuit was overloaded – they had burned out. (Maslach, 1982, p. 3)
Burnout is described by Christina Maslach, one of the first psychologists to explore
the phenomena, as “a syndrome of emotional exhaustion, depersonalization, and reduced
personal accomplishment that can occur among individuals who do “people work” of some
kind” (Maslach, 1982, p. 3). Maslach considered burnout to be one type of job stress, arising
specifically from the social interaction between helper and recipient. In this sense burnout
was a response of dealing with other people, particularly the chronic emotional strain of
working with people who had difficulties (Maslach, 1982).
Maslach’s (1982) explorations into the syndrome identified how three factors of
burnout might develop over time. A helper may become emotionally overinvolved with their
recipients. Feeling overwhelmed by the emotional demands imposed by recipients onto them,
could result in the first factor of burnout: emotional exhaustion. This may lead to the helper
feeling unable to give anymore, withdrawing from involvement with recipients and detaching
17
themselves psychologically. When this detachment is balanced with genuine caring for
recipients it can be an effective way to handle the emotional strain of the work. The
detachment, however, may develop into cold and callous disregard for recipient’s feelings
and the second factor of burnout: depersonalization. The helper may begin to actively dislike
the recipients, expecting the worst from them. A process of dehumanisation may occur
leading a helper to verbally put recipients down or treat them unkindly. Helpers may fail to
provide the appropriate care or service to recipients. Helper’s behaviours may potentially
become harmful, degrading and abusive. The helper’s behaviour toward recipients may cause
them to feel inadequate, guilty and a failure, leading to the third factor of burnout: reduced
personal accomplishment.
Cordes and Dougherty (1993) describe burnout as a unique stress phenomenon with
emotional exhaustion a traditional stress variable. Depersonalisation is identified as a new
construct and the dimension of personal accomplishment was identified as related to concepts
of self-efficacy. When conceptualised for intellectual disability staff emotional exhaustion
and depersonalisation focus on relationships with or feelings towards service users, whilst
personal accomplishment is a general satisfaction scale focussed on feelings about one’s job
(Rose, Horne, Rose, & Hastings, 2004). From a clinical psychologist’s perspective it is of
interest to find out what demands are associated with staff burnout in order to find out how
interventions might reduce them.
1.6.1. Measuring burnout. The Maslach Burnout Inventory-Human Services Survey
(MBI-HSS. Maslach et al., 1996) is considered the most established measure of burnout and
has provided normative data for use in assessing burnout within services for adults with
intellectual disabilities (Skirrow & Hatton, 2007). The measure consists of three subscales
measuring emotional exhaustion (9 items), depersonalization (5 items) and personal
accomplishment (8 items). It is completed by rating experience of each item on a 7-point
18
frequency scale (0 = never, up to 7 = everyday). Higher scores on each subscale relate to
greater reported feelings of each construct, with high scores of emotional exhaustion and
depersonalisation and low scores of personal accomplishment associated with burnout.
Hastings, Horne and Mitchell (2004) conducted a factor analysis on the MBI-HSS to
consider how the three burnout dimensions of the measure applied specifically to the
intellectual disability staff population compared with other human services workers. The
three dimensions were found to have good construct validity with 19 out of 22 items loading
above 0.4 on the appropriate factor and less than 0.4 on the other factors. Comparable with
other populations of human services workers, the three dimensions were found to have fair to
good levels of reliability as measured by Cronbach's alpha: emotional exhaustion α = 0.87,
depersonalisation α = 0.68, and PA α = 0.76 (Hastings et al., 2004). These findings suggest
the MBI-HSS is a suitable tool to assess dimensions of burnout in staff working in
intellectual disability services, and its continued popularity as a measure of burnout in this
research field is reason for this one measure to be the target for a systematic literature
review.
The MBI-HSS has been criticised on several grounds: being circular and restrictive in
its ability to be tested with non-human service populations; an unclear relationship between
the measure and the concept of burnout; containing a mixture of an individual state, coping
strategy and an effect; using unacceptable Americanised questions that would not translate
into other cultures; and not being in the public domain (Kristensen, Borritz, Villadsen &
Christensen, 2005).
Kristensen et al. (2005) developed a new measure The Copenhagen Burnout
Inventory (CBI) which has three sub-dimensions: personal burnout, work burnout, and
client/customer burnout. This 19-item measure was developed for a large-scale project
investigating burnout, motivation and job satisfaction in Denmark. The CBI was tested with
19
participants working in a psychiatric prison, social welfare offices, a general health hospital, a
psychiatric hospital, institutions for the severely disabled, and home care services. The CBI
has demonstrated satisfactory reliability and validity, with Cronbach’s alphas reported
between .85 and .87 and test-retest ability as .51 for all subscales (Kristensen et al., 2005).
The CBI is used more frequently to measure burnout within intellectual disability staff
populations in non-English speaking countries (recently Kozak et al., 2013; Lin & Lin, 2013).
1.6.2. How does burnout affect intellectual disability staff? Skirrow and Hatton
(2007) investigated the levels of burnout of intellectual disability staff as measured by the
MBI-HSS through a systematic literature review and meta-analytic comparison of the
average scores found on the three dimensions. A detailed appraisal of the fourteen studies
identified and their findings is provided in this review and therefore won’t be replicated here.
It is of interest, however, to see how burnout and intellectual staff variables had been
investigated up to the point of the review (conducted in 2004). In particular, what significant
and interesting non-significant results had been found (on any of the dimensions of burnout)
and what conclusions could be drawn at that time.
Service user characteristics and burnout were investigated. Burnout was associated
with coping responses and emotional reactions to challenging behaviour (Mitchell &
Hastings, 2001), and with staff members perception of their relationship with service users
(Van Dierendonck, Schaufeli, Buunk, 1996, as cited in Skirrow & Hatton, 2007). No
relationship was found between burnout and level of service user disability or the presence of
challenging behaviour (Chung & Corbett, 1998).
Organisational variables and burnout had been explored. Staff member’s view of the
organisation, feeling rewarded or in need of further support and training were associated with
burnout (Blumenthal, Lavender, & Hewson, 1998; Chung & Corbett, 1998; Van Dierendonck
et al., 1996). Both significant (Gill-Monte & Peiro, 1998) and non-significant associations
20
(Caton, Grossnickle, Cope, Long, & Mitchell, 1988, as cited in Skirrow & Hatton, 2007)
were found between burnout and supervisory support. Differences between levels of burnout
of staff in community-based and hospital-based services were also found to be significant
(Aitken & Schloss, 1994; Chung & Corbett, 1998).
Burnout was found to be significantly associated with aspects of perceived job role,
such as conflict, clarity, overload, insufficiency, ambiguity, boundary, and responsibility
(Aitken & Schloss, 1994; Blumenthal et al., 1998; Gill-Monte & Peiro, 1998) and feeling
under-utilized (Caton et al.,1988, as cited by Skirrow & Hatton, 2007). Perceived
consultation with and social support from work colleagues was also significantly associated
with burnout (Gill-Monte & Peiro, 1998). Differences between job role, education and
qualifications and burnout produced significant (Aitken & Schloss, 1994; Chung & Corbett,
1998; Mitchell & Hastings, 2001) and non-significant results (Edwards & Miltenberger,
1991, as cited by Skirrow & Hatton, 2007).
Investigating staff well-being Aitken & Schloss (1994) reported moderate correlations
between burnout and scores on specific measures of depression, anxiety, and psychological
strain, and found significant negative associations between burnout and personal resources of
recreation, self-care, social support, and coping strategies. Significant differences were found
between burnout and demographic variables of gender (Mitchell & Hastings, 2001) and years
of experience (Chung et al., 1996). In terms of staff behaviour a negative association was
found between burnout and observed positive client interaction, and burnout and intention to
resign (Lawson & O’Brien, 1994, as cited in Skirrow & Hatton, 2007).
Distinct from the correlational studies mentioned above two longitudinal studies
investigated levels of burnout. Boumans & van den Berg (2000) found no changes over time
in levels of burnout reported pre- and post-implementation of person-centred approaches.
During a move from a hospital into community residential services Harvey & Burns (1994, as
21
cited by Skirrow & Hatton, 2007) found staff levels of burnout increased significantly over
the 6-month period, but returned to original levels post move.
Skirrow and Hatton (2007) concluded that the levels of burnout amongst intellectual
disability staff in these studies had not differed significantly from the normative sample
described by Maslach et al. (1996). Suggesting that staff in services for adults with
intellectual disabilities may not be at increased risk of burnout compared to staff in other
human services. It was proposed that either working within intellectual disabilities services
was no more challenging than others human service settings, or there were factors associated
with working in intellectual disabilities services that protected staff from becoming burned
out (Skirrow & Hatton, 2007). These studies had been published between 1988 and 2001, a
time when there were many changes in intellectual disabilities service provision. Reductions
over time in emotional exhaustion and depersonalisation scores were noted and suggested
that changes in service structure from large institutions to smaller residential services could
have been as beneficial to staff as they were for service users. Organizational variables were
found to be the most reliable predictors of burnout, specifically service delivery and worker
support.
Skirrow and Hatton (2007) reported difficulty drawing strong conclusions from the
systematic review due to the variety within the studies in terms of measures used and
population’s samples. The fourteen studies were criticised for small sample sizes, and the
poor reporting of data, of sampling techniques, and of assessment measures. It is of interest
therefore to explore out how research conducted since 2004 has developed in light of these
methodological criticisms.
1.6.3. Updating the literature review on intellectual disability staff burnout.
Following the same method as Skirrow and Hatton (2007) a systematic literature review was
conducted to identify how research has progressed and investigated the relationships between
22
intellectual disability staff burnout, as measured by the MBI-HSS, and service user
characteristics, organizational variables, job role, and staff personal variables, well-being, and
behaviour. In particular to see whether studies have improved in quality through larger
sample sizes, with improvements in reporting of data, sampling techniques, and assessment
measures. It also is of interest to see whether studies have tested hypotheses driven from
explicit theoretical models. The method for conducting the review, with inclusion criteria,
search procedure and flow diagram can be found in Appendix A. The sixteen studies found
through this systematic search are detailed in Table 1.2, with details of the study aim,
theoretical perspective, study variables investigated, and measures used.
1.6.3.1. General characteristics of the studies. Study sample sizes varied with the
majority sampling between 34 and 112 participants. Three studies recruited larger numbers of
323 (Gray-Stanley & Muramatsu, 2011), 926 (Hensel, Lunsky & Dewa, 2012) and 1570
participants (Hickey, 2014). The varied number of participants will affect the power of
individual study results, with larger sample studies having more statistical power. Response
rates ranged from 23%to 71%and two studies did not provide this information (Rose et al,
2004; Hensel et al., 2012). This is very similar to the general response rate identified for
studies of intellectual disability staff of between 22% and 75% (Hatton & Emerson, 1995).
Hickey (2014) identified an estimated total response rate of 40% but recognised that
participating agencies varied in their response rates from 4% to 99%.
All studies used samples of convenience; mainly undertaking cross-sectional surveys,
with three studies using a pre- and post-intervention longitudinal design (Bethay, Wilson,
Schnetzer, Nassar & Bordieri, 2013; Hodgkins et al, 2005; Ingham, Riley, Nevin, Evans, &
Gair. 2013), and one study using mixed methodology of a cross-sectional and longitudinal
design (Devereux, Hastings, Noone, Firth, & Totsika, 2009). In terms of sampling, three
studies did not specify the job roles of the participants (Duran, Extremera, & Rey, 2004;
23
Gray-Stanley & Muramatsu, 2011; Hensel et al., 2012), and three studies reported all
participants as being direct care or support workers (Hodgkins et al, 2005; Ingham et al.,
2013; Rose et al, 2004; Rose & Rose, 2005). The remaining studies sampled direct care
workers and other roles: management (Mascha, 2007; Mutkins et al., 2011; Mills & Rose,
2011; Rose, Mills, Silva & Thompson, 2013; Thomas & Rose, 2010), qualified nurses
(Chung & Harding, 2009; Devereux, Hastings, Noone, Firth et al., 2009;Mills & Rose, 2011),
therapists and other professionals (Bethay et al., 2013; Mills & Rose, 2011; Rose et al., 2013)
and administrative staff (Mutkins, Brown & Thorsteinesson, 2011).
The services sampled also varied between independent, voluntary, and government
run services, with three-quarters explicitly recruiting from residential and/or community
services. Hodgkins et al. (2005) and Mascha (2007) sampled staff in adult day services only.
Five sampled a mixture of residential and other intellectual disability services: day (Bethay et
al., 2013; Devereux, Hastings, Noone, Firth et al., 2009; Hensel et al., 2012), respite (Hensel
et al., 2012), hospital or inpatient (Devereux, Hastings, Noone, Firth et al., 2009; Ingham et
al., 2013) and secure services (Rose et al., 2013). Duran et al, (2004) did not go further than
describing ‘institutions for people with intellectual disabilities,’ and Hickey (2014) described
sites as ‘a cross-section of small, medium and large agencies’.
Weiner (1996, as cited by Rose & Rose, 2005); Eisenberger et al. (1986, as cited by
Mutkins, Brown & Thorsteinesson (2011); Ensel and Link (2004 as cited by Gray-Stanley &
Muramatsu, 2011); Hayes (1999, as cited by Bethay et al., 2013); Mash and Johnston (1990,
as cited by Rose et al., 2013).All studies utilised self-report measures using paper based
surveys, paper plus an emailed electronic document (Hickey, 2014), or paper plus an internet
based survey (Mutkins et al., 2011). Self-report measures are widely criticised for social
desirability bias, though none of the reviewed studies used observational methods or real
incident forms to increase ecological validity. Studies investigated different variables and
24
their relationships with staff burnout, using a variety of standardised questionnaires and study
specific Likert scale measures.
Two studies used vignettes as part of the method (Rose et al, 2004; Rose & Rose,
2005), whilst the other 10 questioned real work experiences. Vignettes have been criticised
for being abstract and lacking the emotional relationship that exists between staff and real
clients (Lucas et al., 2009), though it is a way of controlling for client variables. Three studies
used statistical t-tests and ANOVAs to analyse their results (Bethay et al., 2013; Hodgkins et
al., 2005; Ingham et al., 2013), with the remaining studies using correlation analysis. Several
undertook further multiple and hierarchical regression analysis (Chung & Harding, 2009;
Devereux, Hastings, Noone, Firth et al., 2009; Gray-Stanley & Muramatsu, 2011; Mutkins et
al., 2011, Thomas & Rose, 2010) and path analysis (Rose & Rose, 2005; Thomas & Rose,
2010). Mascha (2007) also used qualitative analysis to explore participant responses to open-
ended questions about organisational factors.
The mean scores for the three dimensions of the MBI-HSS reported ranged from
16.56 to 25.46 for emotional exhaustion, from 2.00 to 9.54 for depersonalisation, and from
27.94 to 36.90 for personal accomplishment. In comparison the mean scores reported in the
MBI-HSS handbook are emotional exhaustion 21.0 (SD = 10.8), depersonalisation 8.7 (SD =
7.1) and personal accomplishment 34.6 (SD = 5.9) (Maslach et al., 1996). The majority of
studies reported data for the mean scores on all three dimensions of the MBI-HSS. Devereux,
Hastings, Noone, Firth et al., (2009) and Rose et al, (2004) did not provide any break down of
the MBI-HSS data collected, Gray-Stanley and Muramatsu (2011) only measured and
reported emotional exhaustion, Duran et al., (2004) reported the mean scale scores as
opposed to the mean total scores for each scale, and Ingham et al., (2013) reported mean total
MBI-HSS scores. Mills and Rose (2011) reported emotional exhaustion and personal
25
Table 1.2
Summary of studies included in the systematic review
Authors
and
Country
Sample Theoretical
model
Aims of study
investigation
Study variables (other than
burnout): Measures used
Main Study findings and mean
scores on dimensions of the MBI-
HSS (Standard deviations)
Rose,
Horne,
Rose &
Hastings
(2004)
UK
Study 1
N =
101
Study 2
N = 99
No explicit
theoretical
model
Association between
negative emotional
reactions to
challenging behaviour
and staff well-being
Study 1
Negative Emotions: Emotional
Reactions to Challenging
Behaviour Scale
Study 2
Challenging behaviour: Three
vignettes, Likert scales rating
emotions
Significant positive correlations
found between negative
emotional reactions and EE and
DP burnout.
Mean EE, PA and DP scores not
reported
Duran,
Extremera,
& Rey
(2004)
Spain
N =
112
No explicit
theoretical
model
Relationship between
Trait Meta-Mood
Scale and burnout,
and engagement
1. Emotional Intelligence:
Spanish Trait Meta-Mood Scale
2. Engagement: Utrecht Work
Engagement Scale
Emotional clarity and repair to
mood significantly associated
with PA.
EE, DP and PA mean item scores
provided instead of mean
subscale score.
Hodgkins,
Rose, &
Rose
(2005)
UK
Pre:
N = 46
Post:
N = 36
No explicit
theoretical
model
One-day workshop
intervention on
reduction of stress
levels
1. Perceptions of strain, demands
and supports: Demands and
support questionnaire, Staff
support questionnaire
2. Perceptions of the team: Team
climate inventory.
(Only a pre-intervention
measure)
3. Anxiety: Likert Scale
Post-intervention reductions in
levels of anxiety and emotional
exhaustion.
EE: 43 pre = 17.37 (10.33)
34 post = 11.73 (7.41)
DP: 45 pre = 2.00 (3.38)
33 post = 2.33 (3.60)
PA: 40 pre = 34.82 (7.59)
32 post = 33.81 (8.97)
26
Rose &
Rose
(2005)
UK
N =
107
Weiner
(1996)
model of
attributions
and helping
behaviour
1. Explicit model for
impact of perceived
stress on quality of
care provided
2. Can attributions
explain a greater
proportion of the
variance
1. Attributions: Attribution Style
Questionnaire
2. Emotion reactions: Likert scale
3. Optimism for changing
Challenging Behaviour: Likert
scale
4. Helping behaviour: Likert
scale
5. Perception of Stress: General
Health Questionnaire
6. Challenging Behaviour:
Aberrant Behaviour Checklist
High stress levels and moderate
burnout did not relate to reports
of thoughts and feelings regarding
challenging behaviour.
EE: 25.46 (11.54)
DP: 9.54 (6.12)
PA: 27.94 (7.21)
Mascha
(2007)
UK
N = 36
No explicit
theoretical
model
1. Burnout in day
services
2. Sources of support
and stress
3. Role clarity, job
satisfaction,
supervision, and
propensity to leave
4. Coping strategies
5. Demographic
variables
1. Working environment: 23
open-ended questions
2. Staff support: The Staff
Support Questionnaire
3. Coping: The Shortened Ways
of Coping Questionnaire
Wishful thinking as a coping
strategy, and satisfaction with
supervision were significantly
associated with EE. Greater
wishful thinking was associated
with lower PA.
EE: 21.5 (13.9)
DP 4.8 (4.9)
PA: 35.5 (6.7)
Devereux,
Hastings,
Noone,
Firth &
Totsika
(2009)
UK
Data 1:
N = 96
Data 2:
N = 38
Lazarus and
Folkman
(1984)
transactional
model of
stress
1. Mediating or
moderating effects of
coping and support
between perceived
work demands and
burnout 2. Explore
coping and support in
predicting burnout
over time
1. Perceptions of demands: Staff
Stressor Questionnaire
2. Coping: The Shortened Ways
of Coping Questionnaire
3. Support: Staff Support and
Satisfaction Questionnaire
Significant association between
work demands and EE, and the
relationship was partially
mediated by wishful thinking
coping Practical coping thinking
associated with PA .
Mean EE, DP and PA scores not
reported
27
Chung &
Harding
(2009)
UK
N =
103
No explicit
theoretical
model
Impact of five
personality traits on
burnout and
psychological well-
being
1. Challenging Behaviour:
Aberrant Behaviour Checklist
2. Psychological Well-being:
General Health Questionnaire
3. Personality: NEO-Five
Factor Inventory
Staff perception of challenging
behaviour predicted burnout.
Personality traits predicted
burnout and psychological well-
being.
EE: 20.59 (11.99)
DP: 4.85 (5.49)
PA: 35.29 (7.79)
Thomas &
Rose
(2010)
UK
N = 95
Reciprocity
and equity
theory
1. Relationship
between reciprocity,
burnout, emotional
and physical
withdrawal from care
2. Negative emotions
and optimism
1. Global Reciprocity: Global
Reciprocity Measure
2. Specific Reciprocity: Specific
Reciprocity measure
3. Optimism: Likert scale
4. Helping behaviour: Likert
scale
5. Mood: The positive and
negative affect schedule
Association was found between
lack of reciprocity and levels of
burnout. Burnout was correlated
with emotion, optimism, and
helping behaviour.
EE: 16.56 (14.15)
DP: 4.25 (5.08)
PA: 35.13 (8.56)
Mutkins,
Brown &
Thorstein-
esson
(2011)
Australia
N = 80
Eisenberger
et al. (1986)
social
exchange
theory
Direct and indirect
associations between:
client challenging
behaviour, perceived
stress, anxiety,
depression, social and
organisational
support, burnout
1. Challenging Behaviour:
Likert scale
2. Mood: Depression, Anxiety
and Stress Scale
3. Organizational support:
Survey of Perceived
Organizational Support short
version
4. Social support: Social
Support Questionnaire short
version
Depression symptoms and
organisational support were
associated with greater EE and
DP. Less social support was
associated with less PA.
EE: 17.90 (12.84
DP: 4.68 (4.68)
PA: 34.71 (9.17)
28
Gray-
Stanley &
Muramatsu
(2011)
USA
N =
323
Ensel and
Link (2004)
life stress
model
1. What types of work
stress are related to
burnout
2. How social and
personal resources
contributed to lower
burnout
1. Work stress: 26 item Likert
scale
2. Work social support: 10 item
Likert scale
3. Locus of control: 8 item
Likert scale
Work overload, limited
participation decision-making,
client disability care, were
positively associated with EE.
EE: 19.19 (±13.34)
Mills &
Rose
(2011)
UK
N = 77
No explicit
theoretical
model
1. Cognitive variables
2. Challenging
behaviour and
burnout 3. Cognitive
variables and burnout
4. Mediating
relationship of
cognitive variables
1. Challenging Behaviour:
Checklist of Challenging
Behaviour
2. Cognitive Variables:
Challenging Behaviour
Perception Questionnaire,
Controllability Beliefs Scale,
Fear of Assault Measure
Positive associations found
between challenging behaviour
and burnout, challenging
behaviour and cognitive
variables, and cognitive variables
and burnout.
EE: 19.86
PA: 36.39
Hensel,
Lunsky &
Dewa
(2012)
Canada
N =
926
No explicit
theoretical
model
Association between
frequency and
severity of exposure
to client aggression
and burnout
1. Client aggression: Likert
scales
2. Perception of severity of
Challenging Behaviour: Rating
on scale 1-100
Exposure to aggression was
positively associated with EE and
DP.
EE: 18.7 (11.5)
DP: 4.7 (7.5)
PA: 36.9 (4.9)
Bethay,
Wilson,
Schnetzer,
Nassar,
Bordieri
(2013)
USA
Pre and
post
N = 34
Hayes
(1999)
model of
acceptance
and
commitment
training
Effects of a workshop
combining acceptance
and commitment
training with training
in applied behaviour
analysis
1. Well-being: General Health
Questionnaire-12
2. Burnout Believability Scale:
13-item Likert scale
3. Social Validity Survey: 6-
item Likert scale
ACT group participants with
higher levels of distress pre-test
showed greater reductions in
psychological distress post-test,
and decreased in believability of
burnout-related thoughts
observed pre-test to follow-up.
29
ACT+ABA group:
EE – Pre: 16.78 (13.32)
Post: 15.44 (10.53)
DP – Pre: 5.50 (3.99)
Post: 5.72 (3.92)
PA - Pre: 33.44 (8.05)
Post: 31.61 (10.52)
ABA group:
EE - Pre: 17.81 (11.03)
Post: 17.50 (11.42)
DP - Pre: 4.13 (3.12)
Post: 3.25 (2.98)
PA - Pre: 33.19 (9.81)
Post: 34.75 (8.01)
Ingham,
Riley,
Nevin,
Evans &
Gair
(2013)
UK
Work-
shop
group
N = 37
Compa
-rison
group
N = 21
Lazarus &
Folkman
(1984)
transactional
model of
stress
A brief workshop on
resilience
1. Emotional responses to
aggressive challenging
behaviour
2. Helpful aspects of workshop
questionnaire
Following the workshop negative
emotional reactions to
challenging behaviour reduced,
but burnout did not.
Only total MBI scores were
provided pre- and post-workshop
Rose,
Mills,
Silva, &
Thompson
(2013) UK
N =77
Mash and
Johnston
(1990)
model of
stress in
parent child
interactions
1. Use model
proposed to examine
well-being,
challenging
behaviour, therapeutic
environment 2. Is
relationship mediated
by fear of assault
1. Fear of assault: 2-item Likert
scale
2. Challenging Behaviour:
Checklist of challenging
behaviours
3. Modified version of Essen
Climate
4. Evaluation Schema: 15-item
Likert Scale
The relationships between
challenging behaviour and EE,
and experience safety and EE
were mediated by fear of assault.
EE:19.86 (11.09)
DP: 4.72 (5.38)
PA: 36.4 (6.67)
30
Hickey
(2014)
Canada
N =
1570
No explicit
theoretical
model
Test moderating
effects of prosocial
motivation on the
association of stress
and burnout
1. Well-being: Positive Affect
and Negative Affect Scale
2. Job satisfaction: 9-item Likert
scale
Affective Commitment Scale
3. Occupational Role:
Occupational Role
Questionnaire
4. Prosocial motivation: 6-item
Likert scale
Prosocial motivation moderated
the association of EE and role
boundary stress with DP.
Prosocial motivation moderated
the effects of role ambiguity
stress with a sense of PA.
EE:16.83 (10.27)
DP: 3.36 (4.18)
PA: 38.77 (6.77)
Note. EE = emotional exhaustion. DP = depersonalisation, PA = personal accomplishment.
Weiner (1996, as cited by Rose & Rose, 2005); Eisenberger et al. (1986, as cited by Mutkins, Brown & Thorsteinesson (2011); Ensel and Link
(2004 as cited by Gray-Stanley & Muramatsu, 2011); Hayes (1999, as cited by Bethay et al., 2013); Mash and Johnston (1990, as cited by Rose
et al., 2013).
31
accomplishment only though the same data was used in the study by Rose et al. (2013) which
provides the mean scores on all three dimensions including depersonalisation. These sixteen
studies will now be grouped by variables investigated and appraised in light of the above
methodological considerations.
1.6.3.2. Client characteristics. Eight studies investigated the relationship between
client characteristics and staff burnout. Four studies measured staff experiences of
challenging behaviour with standardised measures widely used in intellectual disability
assessment and research: The Aberrant Behaviour Checklist (Aman & Singh, 1986) and the
Checklist of Challenging Behaviours (Harris, 1994). The other four studies used individual
Likert scales with between one and three items asking about the frequency, severity and
topography of challenging behaviour (Hensel et al., 2012; Mutkins et al., 2011; Rose et al,
2004; Thomas & Rose, 2010).
Gray-Stanley and Muramatsu (2011) conducted multiple regression analysis and
found client disability, work overload and limited decision-making positively predicted
emotional exhaustion. Three studies found the greater the level of staff exposure to
challenging behaviour the higher the level of emotional exhaustion (Chung & Harding, 2009;
Hensel et al., 2012; Mills & Rose, 2011), though two studies found no significant
relationships (Mutkins et al., 2011; Rose & Rose, 2005). Hensel et al. (2012) found in a large
sample that the greater the level of exposure the higher the sense of personal
accomplishment. This may support the finding of Howard et al. (2009) that staff in services
with higher levels of challenging behaviour report higher levels of self-efficacy, with possible
links between self-efficacy and personal accomplishment.
All these studies used self-report measures about exposure to challenging behaviours,
which may be unreliable or biased due to social desirability affects. Specifically many studies
did not report the validity and reliability of the Likert scales used. Hensel et al. (2012)
32
reported their Likert scale measure as being used before, though the previous research was
conducted within educational services (Hastings & Brown, 2002) and has not been replicated
in intellectual disability staff research.
1.6.3.3. Organisational variables. Six of the studies investigated the relationship
between organizational variables and staff burnout. Mascha (2007) reported higher levels of
staff emotional exhaustion associated with lower levels of staff satisfaction with sources of
support, role clarity and job satisfaction. The sample size of this study was small (N = 36) and
the large number of comparisons made, without explicit use of adjusted p-values, increased
the likelihood of Type I errors and affects the power of these results. Gray-Stanley and
Muramatsu (2011) found the level of staff social support made a difference to level of
emotional exhaustion when work load was perceived to be high, whilst locus of control was
associated with lower emotional exhaustion when workload was perceived to be low. Hickey
(2014) supported this result, finding workload stress and related organizational factors
predicted emotional exhaustion. Negative correlations were found between personal
accomplishment and a lack of reciprocity with the organization (Thomas & Rose, 2010), and
between levels of emotional exhaustion and depersonalisation with perceived organizational
support (Mutkins et al., 2011).
Hierarchical regression analysis found organizational support had a moderating effect
when predicting personal accomplishment (Devereux, Hastings, Noone, Firth et al., 2009).
Affective organisational commitment and job satisfaction were positively associated with
personal accomplishment (Hickey, 2014). These results show some support for equity theory
of work stress, and identifies how clinical intervention may target improving staff support
structures within an organisation, through supervision and team meetings. A limitation of
these studies is the use of cross-sectional correlation designs leading to no causal inferences
33
about whether staff perceptions of organizational variables are a symptom of burnout or a
precursor to burnout.
1.6.3.4. Personal and demographic variables. Eight studies investigated the
relationship between staff burnout and staff personal variables. Duran et al. (2004) found
staff reports of emotional clarity and repair to moods, two subscales of a standardised
emotional intelligence measure, were moderately associated with high personal
accomplishment. Duran et al. (2004) reported the mean score on subscales of the MBI-HSS
as opposed to the mean total scores for the subscales which are provided in the other studies,
which limits the ability to compare and generalise their findings.
Two studies found wishful thinking coping was associated with higher levels of
emotional exhaustion and lower levels of personal accomplishment (Devereux, Hastings,
Noone, Firth et al., 2009; Mascha, 2007). The reliability of the standardised questionnaire
used by Devereux, Hastings, Noone, Firth et al., (2009) was low (wishful thinking subscale α
= .63 after removal of three items). Chung and Harding (2009) found the personality trait of
neuroticism was associated with greater emotional exhaustion, and less personal
accomplishment, whilst Mutkins et al. (2011) found the higher the level of social support the
higher the level of personal accomplishment. Two studies found no significant relationships
between personal variables and burnout (Mills & Rose, 2011; Rose et al, 2004). These results
add to the findings of Hatton, Rivers et al. (1999) and Mitchell and Hastings (2001), and
offers further support to a cognitive-behavioural theory of work stress, highlighting how
stress management interventions based on a cognitive-behavioural model could be delivered
to staff teams to reduce wishful thinking coping strategies.
Hickey (2014) found moderate associations between prosocial motivation and
personal accomplishment, and found prosocial motivation had a moderating effect between
emotional exhaustion and depersonalisation. These findings are from a very large sample
34
which supports the power of these results, though the effect sizes were moderate, but the
study did not explicitly test any specific model of work stress. This result was interpreted to
suggest that prosocial motivation might buffer the effect of emotional exhaustion against
deterioration of support workers relationships with clients, and emotional exhaustion might
not result in negative outcomes for staff and client (Hickey, 2014). It is difficult to infer from
the report what exactly Hickey (2014) is using the term prosocial motivation to mean. The
aim of the abstract suggested that the study is exploring the desire to engage in work that is
beneficial to others but it would have been helpful to have an explicit definition within the
text.
In terms of demographic variables, Mascha (2007) found a significant difference
between feelings of depersonalisation and marital status, with single staff reporting more
feelings of depersonalisation compared with married or divorced/separated staff. Mutkins et
al. (2011) also found depersonalisation was related to depression in male participants for
support staff, but was not for administrative/managerial staff. The results of this study need to
be considered in light of the mixed sample population of staff positions, recognising that
different roles may be exposed to different types of work stressors.
1.6.3.5. Staff well-being and behaviour. Five studies investigated the relationship
between burnout, and staff well-being or behaviour. Three studies identified positive
relationships between emotional exhaustion and depersonalisation, and negative emotional
reactions to challenging behaviour (Rose et al, 2004; Rose & Rose, 2005; Thomas & Rose,
2010). Undertaking structural equation modelling with emotional exhaustion Rose and Rose
(2005) found a significant (but not close) fit of the data for the variables of staff optimism,
empathy, negative emotions, and global attributions. Rose et al. (2004) and Rose and Rose
(2005) used vignettes which affects the validity of the results, and Rose et al. (2004) was a
brief report lacking details of the methodology and the analysis. Mills and Rose (2011) found
35
positive correlations between levels of burnout and cognitive variables of perceived negative
consequences, perception of control, perceived negative emotions and fear of assault
associated with challenging behaviour.
Investigating personal well-being, Mutkins et al. (2011) found a positive correlation
between levels of emotional exhaustion and depersonalisation, and staff levels of stress,
anxiety and depression. Hickey (2014) supported this, finding a positive association between
emotional exhaustion and negative feelings, and a negative association between emotional
exhaustion and positive feelings.
Though not explicitly testing a particular theoretical model Mills and Rose (2011)
found the more control staff felt over challenging behaviour, the more personal
accomplishment they reported, in line with attribution theory. Thomas & Rose (2010) used
social exchange theories of reciprocity (through a model based on Weiner’s attribution
theory) and found positive correlations between staff personal accomplishment, positive
emotion, optimism and willingness to offer extra help to clients with challenging behaviour in
line with attribution theory. This supports previous research findings of positive aspects of
staff psychological well-being being significantly associated with personal accomplishment
at work (Hastings & Horne, 2004). Thomas & Rose (2010) measured optimism and helping
behaviour variables using single Likert scales, leading to questions about their validity as
measures of actual helping behaviour. Rose and Rose (2005) used a similar Likert scale to
measure helping behaviour but found their results severely skewed.
1.6.3.6. Intervention and longitudinal studies. Four studies undertook longitudinal
studies of staff burnout. Devereux, Hastings, Noone, Firth et al., (2009) followed up their
initial investigation of staff perception of demands at work, staff support and satisfaction,
coping style, and burnout 22 months later and found that emotional exhaustion was relatively
stable. They suggested that negative dimensions of staff burnout (emotional exhaustion and
36
depersonalisation) are long-lasting, whilst positive dimensions are less so (personal
accomplishment).
Three studies presented the findings from interventions using stress–management and
problem-solving techniques (Hodgkins et al., 2005), mindfulness and acceptance-based
(Bethay et al., 2013), and cognitive-behavioural and acceptance and commitment therapy
(ACT) approaches (Ingham et al., 2013). Hodgkins et al., (2005) found their one-day
workshop significantly reduced mean staff emotional exhaustion and anxiety three months
post-intervention. This study did not use a control group therefore it is unknown whether
other changes occurred within the organisations at the same time that could have affected
these results. The intervention does not appear to be based on explicit theory and the research
is only briefly described (article <1700 words) giving a concise overview of the study and
intervention. It would have been helpful to have more detail for replication purposes.
Bethay et al.’s (2013) report provides clear details of the intervention which is based
on theory (ACT), and compares intervention results with a control group. However the
validity of the results need to be considered in light of the small sample of 14 participants.
The intervention involved three sessions of didactic teaching about stress in the workplace
and the ACT model, reflections on work stressors, thoughts, emotions and coping strategies,
experiential mindfulness and ACT exercises, and applied behavioural analysis (ABA).The
intervention group (ACT+ABA group) and the comparison group (ABA group) both received
lectures about ABA, the intervention group for three hours and the ABA group for nine
hours. No significant differences on dimensions of burnout were found between the two
groups pre- or post-intervention during both primary and secondary analyses.
Subsequent post-hoc investigations found significant differences were identified on
social validity measures, with participants in the ACT+ABA group significantly more likely
to agree that the intervention had improved working relationships. Participants showing the
37
highest levels of distress (above the clinical cut-off point on the General Health
Questionnaire-12) and attending the ACT+ABA group showed significantly greater reduction
in distress post-intervention compared with the ABA group, which shows the intervention
might be most helpful for those experiencing the highest levels of distress. The results of
these post-hoc investigations need to be considered carefully as they were not part of the
planned hypothesis-testing.
Ingham et al.’s (2013) workshop involved experiential tasks and reflective discussions
and aimed to improve psychological resilience. No significant differences were found pre-
and post-intervention on measures of burnout for the 31 participants who attended the
workshop. A significant difference was found pre- and post-intervention on a measure of
emotional responses to aggressive challenging behaviour, whilst there was no difference on
this measure for the control group. It was suggested that this provided some evidence for
interventions within Lazarus and Folkman’s (1984) transactional model of stress, aiming to
have an impact on cognitive and emotional mediators of stress for staff. However there was
no change in level of burnout meaning the reduction in negative emotions did not affect the
relationship between staff experience and burnout. The authors only provided the results of
analysis of the total mean scores on the MBI-HSS instead of breaking it down into the three
dimensions, which makes it difficult to generalise and compare these results with the other
studies discussed here.
Two of these studies lost participants during follow-up, Hodgkins et al.’s (2005)
numbers decreased from 43 to 34 with no explanations for drop-out, whilst participants from
Devereux, Hastings, Noone, Firth et al.’s (2009) study decreased from 96 to 38 participants
longitudinally. The reduction in participants within these studies could bias the results. For
example participants who did not find the intervention successful or who had high levels of
38
emotional exhaustion may have been less inclined to complete follow-up measures or left
their jobs at the time of follow-up.
1.6.3.7. Discussion of literature review. Given the wide range of samples within the
16 studies reviewed here, it remains difficult to draw firm conclusions in this research area.
Whilst the search criteria included only studies that were investigating staff working with
adults with intellectual disabilities in community services, this review has revealed the
mixture of services, organizational cultures, job roles and qualifications sampled within
research into this population. A total of 34 different standardised and study specific measures
were used to survey variables of client characteristics, organization, job role, staff
demographics, staff personal wellbeing, and staff behaviour, and their relationship with one
measure of burnout, the MBI-HSS (Maslach et al., 1996). There was a wide range of MBI-
HSS mean subscale scores reported across 10 of the studies on the three dimensions of
emotional exhaustion, depersonalisation, and personal accomplishment. Only one study’s
(Rose & Rose, 2005) mean score for personal accomplishment fell outside one standard
deviation from the normative data reported in the MBI handbook (Maslach et al., 1996).
Studies that used standardise measures of challenging behaviour, such as the
Checklist of Challenging Behaviour and the Aberrant Behaviour Checklist were appraised to
be more robust. Many studies that used Likert scales of three or less items to measure
frequency, severity and topography of challenging behaviour did not provide information
about the scales validity and reliability. This made it harder to trust significant results and
compare findings with other studies in the review. It would also be difficult to replicate the
study methods. Likert scales were used to measure study variables such as helping behaviour
(Rose & Rose, 2005; Thomas & Rose, 2010) which raised questions about how valid this
could be as a measure of actual helping behaviour.
39
Study findings from smaller samples (Bethay et al., 2013; Mascha, 2007) were
considered to have less power due to the high number of correlations that were conducted
with low numbers of participants. Whilst the findings of studies with larger samples (Gray-
Stanley & Muramatsu, 2011; Hensel et al., 2012; Hickey, 2014) were considered to have
greater statistical power. Studies which provided the mean and standard deviations of
participant subscale scores on the three dimensions of the MBI-HSS were appraised to be
more open to comparison with each other and normative data for the questionnaire. It was
harder to do this with the results of the Ingham et al. (2014) study which provided the total
MBI-HSS score and Duran et al., (2004) study which provided mean item scores, and those
that did not provide any breakdown.
Seven of sixteen studies tested hypotheses not derived from explicit theoretical
models. It was harder to understand how clinical implications were drawn from significant
results found in studies without a theoretical underpinning. Supporting attribution theory,
there was limited evidence that the more staff felt in control of client challenging behaviour,
the more personal accomplishment they felt at work (Mills & Rose, 2011), and higher staff
positive emotion and optimism was associated with greater willingness to offer help to clients
with challenging behaviour (Thomas & Rose, 2010). Wishful thinking as a coping strategy
was found in two studies (Mascha, 2007; Devereux, Hastings, Noone, Firth et al., 2009) to be
associated with staff feeling higher levels of emotional exhaustion, and lower levels of
feeling personal accomplishment with work. This is in line with previous research findings
(Hatton et al., 1999, Mitchell & Hastings, 2001) and supports a cognitive-behavioural model
of stress (Lazarus & Folkman, 1984). This is an area that further research could investigate,
specifically looking at staff interventions or training based on this model, as explored by
Ingham et al. (2013), using techniques that may help staff to manage their appraisals and
learn more adaptive coping strategies.
40
There was evidence of associations between staff levels of emotional exhaustion with
lower levels of staff satisfaction with organizational support, of role clarity, and of job
satisfaction (Mascha, 2007, Thomas & Rose, 2010, Mutkins et al., 2011, Gray-Stanley &
Muramatsu, 2011), which supports social exchange theories of inequity in relationships
between staff and their organizations (Schaufeli et al, 1996). The associations described here
could be investigated further, possibly leading to ideas of how to address through
organizational policy perceived and real inequity in staff relationships, or how to manage
perceived inequity in relationships between staff and clients through training.
1.6.4. Summary. This literature review has shown how research into staff burnout has
progressed over the last thirty years and this information was used to develop the present
research study. Rose (2011) acknowledged that the system in which staff work is complex
but research designs probably need to become simpler rather than more complex if they are
going to have real utility. The research findings discussed here offer limited support for
attribution, cognitive-behavioural, and social-exchange theories of stress. This suggests that
future studies could investigate these three theoretical models further, in order to gain a
greater understanding of staff burnout and explore positive perceptions of support work.
Thomas and Rose (2010) reported positive correlations between positive emotions
and levels of personal accomplishment staff felt in their work and Hickey (2014) found
prosocial motivation had a positive affect on staff-client relations and personal
accomplishment. Three studies identified positive correlations between negative emotions
and levels of emotional exhaustion and depersonalisation (Rose et al, 2004, Rose & Rose,
2005 and Thomas & Rose, 2010).
These results support the findings of Bell and Espie (2002) and Hastings and Horne
(2004) that staff experience both positive and negative perceptions of support work, and
positive and negative outcomes in relation to it. Research into intellectual disability work
41
stress and burnout has been criticised for not exploring positive aspects (Devereux, Hastings
& Noone., 2009), whilst the concept has been explored in caregiving populations. Folkman
(1997) undertook a longitudinal investigation with caregiving partners of men with AIDS and
found they experienced both positive and negative psychological states. Lawton et al., (1991)
found caring behaviour provided older adult caregivers with both positive affect and negative
affect, which were unrelated to one another and had difference antecedents.
Skirrow and Hatton (2007) reported that levels of burnout were reducing in
intellectual disability staff suggesting that there may be other factors that protect staff.
Investigating what may be contributing to increasing levels of personal accomplishment
associated with working with people with intellectual disability would be interesting.
Exploring how this operates alongside variables found in the literature review to be
associated with levels of emotional exhaustion and depersonalisation.
1.7. A Theoretical Model Investigating both Positive and Negative Aspects of Caregiving
In the 1980s Lawton and colleagues investigated older adult well-being (Lawton,
Moss, Fulcomer, & Kleban, 1982; Lawton, 1983; Lawton, Kleban & diCarlo, 1984) and
respite services for caregivers (Brody, Saperstein, & Lawton, 1989; Lawton, Brody &
Saperstein, 1989). Considering the growing social problem of older adult care and the effect
of the caregiving process on both giver and recipient the research moved on to focus on the
subjective appraisal of caregiving (Lawton, Kleban, Moss, Rovine, and Glicksman, 1989).
Investigating the caregiving process with spouse and adult child caregivers of elderly parents
suffering from Alzheimer’s disease Lawton, Moss, Kleban, Glicksman, and Rovine (1991)
proposed and investigated a two-factor model of caregiving appraisal and psychological well-
being.
The model was based on Lazarus’ (1966) stress model and studies by Bradburn
(1969) suggesting the independence of positive and negative affect. The development of the
42
two-factor model will now be discussed with reference to how it has been used to explore
caregiving process in other familial caregiving populations, leading to ideas about how it
might be used to understand how factors associated with staff stress, burnout and well-being
interact.
1.7.1. A two-factor model of caregiving appraisal and psychological well-being.
Lawton et al. (1991) used Lazarus and Folkman’s (1984) cognitive-behavioural framework of
stress (as described in Section 1.5.1.3) to investigate caregiving appraisal. Lawton et al.
(1991) conceptualised secondary appraisal as a caregiver’s evaluation of the on-going quality
of their own caregiving. It was postulated that the secondary appraisal mediates between the
demand of caregiving and the outcome of psychological well-being. The degree of disability
of the person being cared for was identified as the objective stressor. Resources were
conceptualised as personal and social. The personal resource was caregiver health and the
social resource was informal caregiving assistance provided by others. Two secondary
appraisals were identified to describe possible evaluations of the caregiving process;
caregiver satisfaction and caregiver burden. Subjectively perceived gains or positive returns
of caregiving were represented by caregiver satisfaction, and subjective loss of personal
freedom and psychological distress attributed directly to caregiving were represented by
caregiver burden.
Psychological well-being was described by Lawton (1983) as “one’s subjective
evaluation of the overall quality of one’s inner experience.” Lawton et al. (1991) considered
well-being to be a measurable outcome of caregiving stress, though they also highlighted the
impact of personality traits, general psychopathology, and situation-specific stressors on a
caregiver’s well-being. Within the proposed two-factor model caregiving appraisals were
seen as an outcome of caregiving. Caregiving appraisal was also a mediator between the
objective stressor and psychological well-being. Two parallel processes were hypothesised to
43
occur depending on the caregiver’s secondary appraisal. Secondary appraisal of caregiving
satisfaction was hypothesised to lead to positive affect. Secondary appraisal of caregiver
burden was hypothesised to lead to negative affect.
Lawton and colleagues’ parallel process hypothesis developed from Bradburn’s two-
factor theory of happiness (Bradburn, 1969). Choosing to study subjective feeling states that
individuals experience in their daily lives Bradburn (1969) used the term psychological well-
being, reporting that the health-orientated cultural concern about mental health was really a
concern about a subjective sense of well-being. The feeling states were classified as positive
and negative, a well-recognised dichotomy. This concept was then translated into an
operation measure, the ‘Affect Balance Scale’. Bradburn and Caplovitz (1965, as cited in
Bradburn, 1969) used this measure to collect systematic data from 2006 respondents, a cross
section of four towns in the United States, asking whether they had experienced several
feeling states during the previous week. Analysis of the data showed individual variations
across the two dimensions and unexpectedly the dimensions were independent from each
other. No correlation was found between the extent of positive feelings a person had
experienced in the previous week and the extent of negative feelings. The difference between
the number of positive and negative feelings was a good predictor of a person’s overall rating
of their own happiness, with greater excess of positive over negative affect increasing the
overall rating of psychological well-being.
From this empirical evidence Bradburn (1969) identified a framework of
psychological well-being. An individual’s position on the dimension of psychological well-
being was the result of their position on two independent dimensions, one of positive affect
and the other of negative affect. As life is a dynamic process an individual’s sense of well-
being would be expected to change as factors that affect positive and negative experiences
change. Bradburn (1969) noted that this model was similar to the one proposed for work
44
satisfaction by Herzberg, Mausner, and Synderman (1959, as cited by Bradburn, 1969).
Namely there was a group of factors such as low pay, poor work conditions, and boss
disagreements that played a role as ‘dissatisfiers’ and another group that played a role as
‘satisfiers.’
Lawton et al. (1991) cited studies by Warr, Barter and Brownbridge (1983) and
Diener and Emmons (1985) and the review of studies by Watson and Tellegen (1985) to
highlight how the views of positive affect and negative affect had been modified since
Bradburn’s (1969) proposed model and it was clearly recognised that positive and negative
affect were different from one another. Lawton et al. (1991) reasoned that caregiving was an
activity positively reaffirming to the caregiver which would bring them satisfaction, though it
also involved a demand that might exceed a person’s resources and therefore increase
caregiving burden. Associated with the two dimensions of psychological well-being,
caregiving satisfaction was proposed to be associated with positive affect but be less effective
in mitigating depression, whilst caregiving burden was proposed to increase depression to a
greater degree than it would diminish positive affect.
1.7.2. Testing the two-factor model of caregiving appraisal with familial
caregivers of older people. Lawton et al. (1991) tested the hypothesised caregiving model,
shown in Figure 1.3, with 285 spouse and 244 adult child caregivers of older adults suffering
from Alzheimer’s disease. The authors undertook structured interviews with volunteers
recruited through support groups, the media and service-giving agencies. Measures used were
four- or five-point rating scales of 20 potential care recipient symptoms, frequency of
caregiver assistance on nine personal-care tasks, a four-item index of self-rated health for
personal resources, and for help received the number (from 0 to 9) of personal-care functions
another informal helper had assisted the caregiver with over the previous 12 months. To
investigate caregiving appraisal 15 items from the Burden Interview (Zarit et al., 1980, as
45
cited by Lawton et al., 1991) were used, 5 items for caregiving satisfaction and 10 items for
subjective caregiving burden. The 5 items from the positive affect scale of the Affect Balance
Scale (Bradburn, 1969) and the 20 item Epidemiological Studies Depression Scale (Radloff,
1977, as cited by Lawton et al., 1991) were used to investigate the two dimensions of affect.
Structural equation modelling was used to see if there were significant relationships as
hypothesised between the variables and if the collected data fitted the model. Lawton et al.
(1991) found the hypothesised model shown in Figure 1.3 fit the data for spouse caregivers.
Figure 1.3. Caregiving model for spouse and adult caregivers (C G) hypothesised by
Lawton, Moss, Kleban, Glicksman, and Rovine (1991). Entries are LISREL estimates for
spouse caregivers. I P Symptoms means the degree of disability of the person being cared for.
Looking at the objective stressor, the higher degree of disability a care recipient had
the more help was given by the caregiver and the greater burden experienced by the
caregiver. The objective stressor itself was unrelated to caregiver satisfaction or either
dimension of affect. For resources, more problems with caregiver health correlated with
greater burden, less positive affect, and higher negative affect. The amount of help received
46
by the caregiver correlated with the amount of caregiver help provided, but was not
associated with caregiving satisfaction or burden. Higher levels of caregiver satisfaction led
to higher levels of positive affect, whilst higher caregiver burden led to higher levels of
negative affect.
The same model shown in Figure 1.3 was hypothesised for adult child caregivers but
the data did not fit the model well. The hypothesised paths between caregiver health and
caregiving satisfaction, and between help received and caregiver satisfaction and burden were
not significant. The hypothesised path between caregiver satisfaction to positive affect was
not significant either. The other hypothesised paths were significant in a similar way to the
spouse caregivers.
Conclusions drawn from the initial test of the two-factor model of caregiving
appraisal and psychological well-being were reported separately for caregiver group of
spouse and for adult child, recognising the difference of marital commitment to the
caregiving process. The research recognised the use of a model that considers appraisals and
outcomes of positive affect and negative affect, but the data did not support the separate
hypothesised pathways linking the two types of caregiving appraisal with the two types of
psychological well-being (Lawton et al., 1991).
1.7.3. Use of the two-factor model in other populations. Lawton et al.’s (1991) two-
factor model has since been investigated within populations of family carers of children who
have developmental and mental health disabilities (Pruchno, Patrick, & Burant, 1996),
individuals with traumatic brain injury (Chronister et al., 2010), and adults and children with
intellectual disabilities (Hastings, Beck & Hill, 2005; Hastings & Taunt, 2002; Smith, 1996).
There is one previous example of the two factor model being tested with intellectual
disability staff. Hastings and Horne (2004) tested a newly adapted measure the Staff Positive
Contributions Questionnaire with 101 support staff, who also completed the MBI-HSS and a
47
measure of anxiety and depression. Participant scores on the positive contributions
questionnaire were significantly but weakly (r (99) = .24, p < .05) associated with personal
accomplishment, with no association with emotional exhaustion, depersonalisation, anxiety
or depression. Hastings and Horne (2004) concluded that staff experience a range of positive
perceptions about their work, and this warranted further explanation. There does not appear
to be any published research building on the findings of Hastings and Horne (2004) and
recently this theoretical framework has been identified as an area for further investigation
(Hastings, 2010; Rose, 2011).
1.8. The Research Study
The present study is interested in building on the findings of Hastings and Horne
(2004) to explore both positive and negative aspects of support work with adults with
intellectual disabilities and challenging behaviour. Through the structure provided by Lawton
et al.’s (1991) two factor model of caregiving appraisal and psychological well-being,
cognitive-behavioural theory of work stress (Lazarus & Folkman, 1984) and evidence from
the research literature on staff burnout, a preliminary exploration of a theoretical staff well-
being model will be undertaken.
1.8.1. Conceptualising the model. Stressors, resources, appraisals and outcome were
identified from empirical research exploring factors associated with staff stress, burnout and
well-being.
1.8.1.1. Stressors. Clients’ disability and type of challenging behaviour have both
been identified as predictors of symptoms of burnout (Chung & Harding, 2009; Gray-Stanley
& Muramatsu, 2011; Hatton et al., 1995; Hensel et al., 2012; Mills & Rose, 2011; Vassos &
Nankervis, 2012). Organizational demands in the form of work overload and role ambiguity
have also been found to be positively associated with staff burnout (Gray-Stanley &
Muramatsu, 2011; Vassos & Nankervis, 2012).
48
1.8.1.2. Resources. Emotion-focused coping strategies (e.g. wishful thinking) were
found to relate to higher levels of emotional exhaustion, and to mediate the relationship
between work demands and emotional exhaustion, whilst problem focused coping was found
to predict personal accomplishment (Devereux, Hastings. Noone, Firth et al., 2009; Hatton et
al., 1999; Mascha, 2007; Mitchell & Hastings, 2001). Mutkins et al. (2011) found that higher
social support was related to higher personal accomplishment.
1.8.1.3. Appraisals. For intellectual disability staff the emotional exhaustion
dimension of burnout is focused on the relationship or feelings of staff towards services users
(Rose et al., 2004). Lower levels of staff satisfaction with sources of support, job, and
perceived organisational support have been associated with higher levels of burnout (Gray-
Stanley & Muramatsu, 2011; Mascha, 2007; Mutkins, et al., 2011). Personal accomplishment
is recognised as a general satisfaction scale focussed on feelings about one’s job (Rose et al,
2004). Higher levels of exposure to aggressive behaviour, more control over challenging
behaviour, affective organisational commitment, job satisfaction, emotional intelligence, and
prosocial motivation have all been positively associated with personal accomplishment
(Duran et al., 2004; Mills & Rose, 2011; Hensel et al., 2012; Hickey, 2014).
1.8.1.4. Outcomes. Staff experience both positive and negative attitudes and emotions
towards adults with intellectual disabilities (Bell & Espie, 2002). Negative emotional
responses of staff to challenging behaviour, and staff symptoms of depression have been
associated with higher levels of burnout (Horne et al., 2004; Mutkins et al., 2011; Rose &
Rose, 2005; Thomas & Rose, 2010). Positive emotions were found to be significantly
associated with personal accomplishment at work (Hastings & Horne, 2004; Thomas & Rose,
2010). Positive aspects of psychological well-being were not correlated with the two negative
dimensions of burnout (Hastings & Horne, 2004).
49
1.8.2. The staff well-being model. A new staff well-being model (SWM) is
hypothesised, shown in Figure 1.4, using significant associations found during empirical
research investigating staff stressors, resources, appraisals, and outcome. The severity of
intellectual disability and perception of challenging behaviours of the service users being
supported, and organisational demands are identified as objective stressors. Resources are
conceptualised as organisational and personal. The organisational resources are perceptions
of organisational support. The personal resources are social support and coping mechanisms
used to manage stressful situations: practical coping and wishful thinking.
Figure 1.4. The conceptual Staff Well-being Model and hypothesised relationships. Hn:
hypothesised pathways. Original in colour.
A support worker’s evaluation of the on-going quality of their own work is
conceptualised as the secondary appraisal, mediating between the demand of support work
Wishful
thinking
H3
Personal
accomplishment
H8
Intellectual
disability
H1
Positive
affect H4
H7
St
aff
ch
ara
cte
ris
tic
s
OUTCOMES APPRAISALS STRESSORS and RESOURCES
Challenging
behaviour
Negative
affect
H2
Social
support
H6
Organisational
support
Organisational
demands H9 Emotional
exhaustion
H5
Practical
coping
50
and the outcome of psychological well-being. Two secondary appraisals are identified as
possible evaluations of support work: satisfaction and burden. Subjective perceived gains and
satisfaction with one’s job is represented by personal accomplishment. Subjective burden
attributed directly to support work is represented by emotional exhaustion. Psychological
well-being is represented by the two outcomes of positive affect and negative affect.
This is a cross-sectional correlation model that will guide the hypotheses and the data
analysis to follow. Testing the staff well-being model for goodness of fit would require data
from more than 200 participants, an ambitious recruitment number for this thesis study
timeline, but a possibility for future studies.
1.8.3. Study aim. The aim of this preliminary study is to explore nine hypothesised
relationships between staff well-being model variables along two distinct pathways through
which staff appraisals of personal accomplishment and emotional exhaustion are associated
with different dimensions of well-being.
1.8.4. Research questions and hypotheses.
Research Question 1. Are there associations between stressors and appraisals as
conceptualised in the staff well-being model?
Hypothesis 1. Severity of intellectual disability is associated with emotional exhaustion.
Hypothesis 2. Number of challenging behaviours are associated with emotional exhaustion.
Hypothesis 3. Organisational demands are associated with emotional exhaustion.
Research Question 2. Are there associations between resources and appraisals as
conceptualised in the staff well-being model?
Hypothesis 4. Practical coping is associated with personal accomplishment.
Hypothesis 5. Wishful thinking is associated with emotional exhaustion.
Hypothesis 6. Organisational support is associated with emotional exhaustion.
51
Hypothesis 7. Social support is associated with personal accomplishment.
Research Question 3. Are there associations between appraisals and outcomes as
conceptualised in the staff well-being model?
Hypothesis 8. Personal accomplishment is associated with positive affect.
Hypothesis 9. Emotional exhaustion is associated with negative affect.
52
Chapter 2: Method
2.1. Chapter Introduction
This chapter outlines the research methods used to investigate the present study’s
research questions and hypotheses. A total of 47 participants were recruited through
organisations that provide services for adults with intellectual disabilities and challenging
behaviour and through online advertisements. The recruitment procedure and selection
criteria used are outlined with details of the response rate and study sample. Creation of the
online survey is described with information provided about the validity and reliability of the
eight standardised self-report measures used. The procedure from participant recruitment to
completion of the online survey is then reported. Lastly ethical considerations for conducting
an online research survey with adult participants is discussed.
2.2. Design
The study employed a cross-sectional correlational design in the form of an internet
survey. Quantitative data was collected at one point in time using structured self-report
questionnaire measures.
2.3. Participants
2.3.1. Power analysis and sample size. Effect sizes for hypotheses in this study were
identified from previous research on burnout, psychological well-being and staff variables:
.36 for hypothesis one and two (Mills & Rose, 2011; Vassos & Nankervis, 2012), .45 for
hypothesis three (Vassos & Nankervis, 2012), .5 for hypothesis five (Mascha, 2007), 0.53 for
hypothesis six and seven (Mutkins et al., 2011), .61 for hypothesis eight (Thomas & Rose,
2010), and .71 for hypothesis nine (Thomas & Rose, 2010).
A priori power calculations were conducted using G Power (Faul, Erdfelder, Lang &
Bunchner, 2009). Seven comparisons were planned in the original study proposal, therefore
the likelihood of making a type I error was adjusted using the Bonferroni approach (dividing
53
α = .05 by the number of planned comparisons). For one directional tests of correlation, with
the smallest effect size (r) of 0.36, an error probability (α) of .007, and power of 0.80 a total
sample size of 77 participants was required.
The number of comparisons increased from seven to nine after the initial a priori
sample size calculation when it became apparent that two of the original hypothesis had four
comparisons. In the original study proposal hypothesis one and two, and hypothesis six and
seven were combined. Adjusted p-values were calculated post-hoc to compensate for the nine
comparisons (a full description of the method used is provided in section 3.4).
2.3.2. Inclusion and exclusion criteria. Participants were selected by the criteria:
working in a community service for adults with intellectual disabilities, employed in a
support role, access to the internet, computer skills to navigate to and around the survey, and
written English skills. Participants were excluded if they did not identify their current job role
involving direct support work, if they identified working in secure or inpatient services, and if
they did not press the option at the end of the survey to submit their answers.
2.3.3. Recruitment. Recruitment of participants was undertaken through organisations
providing services for adults with intellectual disabilities and through online advertisements
posted on internet forums.
2.3.3.1. Recruitment through organisations. Organisations were identified within the
local geographical area through the County Council website, and through the knowledge of
intellectual disability health practitioners. Organisations were selected that met two criteria:
1. Services in the community e.g. residential, supported living, day, study, or activity
services.
2. Services registered for adults with intellectual disabilities and challenging behaviours.
Services were excluded if they were managed by the National Health Service, if they
provided inpatient or nursing care, and if the service was predominantly for other social care
54
needs such as the elderly or mental health difficulties. In the local area 15 organisations were
identified that had more than one service meeting the selection criteria. Outside of the local
area nine organisations were identified through attendance at an Intellectual Disability
conference and using the author’s knowledge. Organisations were contacted by telephone,
email and face to face and presented with information about the study (see Appendix B).
Organisations were followed-up once by telephone and email if no initial reply. If an
organisation responded with interest in participating communications continued through face
to face meetings, telephone and email contact. A total of eight organisations provided verbal
and written permission for the study to be advertised in their services.
The study was advertised within organisations through face to face meetings with
staff teams, through an advertising poster placed on staff noticeboards (see Appendix B), and
through distribution of a recruitment letter amongst staff (see Appendix B). The method of
recruitment used varied per organisation and subsequently through individual services within
that organisation. The poster and recruitment letter appealed for support staff to participate in
a psychology study investigating how staff cope with the demands of support work and how
this impacts on their job satisfaction and well-being. A brief overview of the research study
was provided, what participation would involve, the web address of the internet study, and
details of a prize draw participants could enter. Participants were offered the chance to enter a
prize draw after they had completed the survey, through which they had the chance to win
one of two Love2shop vouchers worth £50 each. This was to act as an incentive for people to
take part in the research study. The advertising poster had the web address of the internet
survey on tags that could be removed, and a Quick Response code for the web address that
could be scanned into a smart phone or tablet to access the survey directly.
2.3.3.2. Recruitment through online advertisements. Online forums for people
working with adults with intellectual disabilities were identified through internet search
55
providers and through the researcher’s knowledge. Where required permission was sought
from the forum administrator to post an advertisement for the study. A study advertisement
was posted on five forums with a link to the online survey (see Appendix C). The
advertisement and link were subsequently re-posted in other forums by people interested in
sharing the information. Individuals who contacted the researcher with an interest to share the
study details with colleagues were sent an email with the study information for organisations.
2.3.3.3. Response rate. Due to the recruitment methods used it is not possible to
calculate how many people responded to the study advertisements. A total of 459 recruitment
letters were delivered by post or during face to face meetings to services for distribution
amongst staff. Two organisations and nine individual services requested the recruitment letter
to be sent via email and it is not known how many staff were subsequently provided with a
letter. It is impossible to ascertain how many people viewed an online advertisement or
viewed the first page of the online survey. The overall successful response rate can therefore
not be calculated.
In total, 256 people accessed the online survey and went past the first page detailing the
selection criteria to view the participant information sheet. After this, 117 (45.7%) completed
the consent form to progress to the questionnaires, 87 (34%) started or completed the
demographic information, and 57 (22.3%) proceeded to start or complete at least one survey
measure. A total of 50 participants completed all of the questionnaires and agreed to submit
their answers to take part in the study; a completion rate of 19.5%. Response rates for similar
studies with staff in intellectual disability services using paper surveys have ranged from 25%
to 75% (Hatton & Emerson, 1995). In recent studies using both paper and electronic copies of
a survey, a response rate of 25% was reported by Mutkins et al., (2011), whilst Hickey (2014)
reported a range from 4% to 99% within different agencies.
56
2.3.4. Sample. Of the 50 participants who completed the entire survey three were
removed. Two for working in secure or inpatient services, and one for not providing any
direct support during their last five working days. A total of 47 participants were included in
the data analysis; complete demographic information is given in Table 2.1.
Table 2.1.
Descriptive characteristics of participants
Demographic Information Participants
n
Percentage
(%)
Mean
(SD)
Range
Age (years)
Prefer not to answer
41
6
39.45 (13.48) 19.05 – 68.17
Gender
Male
Female
14
33
29.8
70.2
Marital Status
Single
Cohabiting/Married/
Civil Partnership
Separated/Divorced/
Dissolution of Civil Partnership
19
27
1
40.4
57.5
2.1
Current Job Title
Support Worker
Night Support Worker
Senior Support Worker
Managerial position
Training position
25
1
9
9
3
53.2
2.1
19.2
19.2
6.3
Current Working Hours
Full Time
Part Time
Bank
Prefer not to answer
31
8
7
1
66.0
17.0
14.9
2.1
Work Experience
Current Job (years)
Prefer not to answer
Total experience in field (years)
Prefer not to answer
46
1
42
5
6.68 (6.40)
10.05 (8.38)
0.33 – 24.50
0.42 – 35.00
Education and Qualifications
NVQ2 or equivalent
NVQ3 or equivalent
NVQ4 or equivalent
NVQ5 or equivalent
Prefer not to answer
3
15
19
8
2
6.4
32.9
40.4
17.0
4.3
Training on Challenging
Behaviour
No formal training
4
15
8.5
31.9
57
One or Two courses
Three or more courses
Prefer not to answer
27
1
57.5
2.1
Intellectual Disability Service
Residential/supported living
Day or activity service
Study service
Prefer not to answer
34
12
1
0
72.3
25.5
2.1
0
Heard about survey
Organisation
Friend or family
Internet advertisement
Prefer not to answer
23
15
9
0
48.9
31.9
19.1
0
The majority of respondents were female (70.2%), cohabiting or married or in a civil
partnership (57.5%), working full time (66.0%), support workers (53.2%), and had attended
three or more courses about challenging behaviour (57.5%). Participant age ranged between
19 years and 68 years. Experience working in the intellectual disabilities field ranged
between 5 months and 35 years, with between 4 months and 24 years in current employment.
Most participants reported having qualifications at the level of NVQ3 (32.9%) or NVQ4
(40.4%). Job role varied with 26 support workers or night support workers, nine senior
support workers, nine in a managerial role, and three in a staff training role. All participants
undertook at least one direct support task with service users during their last five working
days.
2.4. Measures
The online survey consisted of a brief demographic information section followed by
eight self-report measures (see Appendix D). Each measure is described below with details of
psychometric properties and a rationale for its use in this study. The internal reliability
coefficient (Cronbach’s alpha) should be .7 or higher. A mean inter-item correlation on scales
of between 0.2-0.4 is considered appropriate for personality scales (Briggs and Cheek, 1986).
2.4.1. Internet survey. An internet survey was used to recruit an anonymous and
confidential, geographically diverse sample at low cost. The questions asked to participants
58
about their job and organisation necessitated reassurance that the results would not be fed
back to employers. An internet survey allowed this, to allow participants to complete the
measures in their own time and space without the chance of anyone in their employment
finding out. Challenges of internet research include sample biases of internet users, self-
selection and dropout, and lack of control over data-collection (Kraut et al., 2004). This
includes verifying participant’s identities, and anonymity leading to potential frivolous
completion. To control for these challenges participants were required to disclose their
current job role. Participants were asked about the type of service they worked in and how
they found out about the study. Participant’s responses were systematically checked to
identify anomalous data patterns.
2.4.2. Demographic information. The first section of the survey asked four questions
about demographic information: age, gender, marital status, education and qualifications.
With seven subsequent questions about employment information: current job title, current
working hours, length of experience in current job, length of experience working with adults
with intellectual disabilities and challenging behaviour, training on challenging behaviour,
and description of the service employed in.
These demographic characteristics were collected to compare the sample in the current
study with samples from similar research studies and to generalise the results. Participants
had the option not to answer these questions except for their current job title which was part
of the selection criteria. Participants were asked how they found out about the research
(employer, family or friend, internet advertisement) as a method to check for bias of the
different recruitment methods.
2.4.2.1. Support given to service users. Support given to clients is of interest in this
study as a demographic variable and to check that participants meet the study selection
criteria and are undertaking direct support work. The support given by staff to service users
59
was measured using an adapted version of the measure used by Lawton et al., (1991). The
measure was adapted for the purpose of this study to accommodate the support provided by
staff to adults within intellectual disability services. The item grooming included the prompt
‘making hair, face or skin look nice,’ ambulation became ‘moving from place to place e.g.
support to walk or move, using manual handling techniques,’ transportation included the
prompt ‘ driving a car, using public transport’ and the item ‘to go into the community e.g.
shops, leisure activities, college’ was added.
Participants were asked how frequently they provided this support to a service user over
their last five working days, with four response options from ‘no days’ to ‘four or five days.’
In the Lawton et al. (1991) model the amount of help given by caregiver increased burden,
and was associated with greater caregiver satisfaction. Previous research in this area has not
investigated support given so there is no clear indication on how this variable might correlate
with job satisfaction or burnout in intellectual disability staff.
2.4.3. Stressors. The staff stressors investigated were service user intellectual disability
and challenging behaviour, and organisational demands.
2.4.3.1. Intellectual disability. Participant perception of the category of intellectual
disability of the service users they supported was gathered using ICD-10 (World Health
Organisation, 2010) criteria. Participants were asked to select the most severe category of
intellectual disability they worked with from the options mild, moderate, severe, and
profound.
2.4.3.2. Challenging behaviour. The Checklist of Challenging Behaviour (CCB,
Harris, Humphreys, & Thomson, 1994) measures observed behaviours exhibited by a person
in the last three months. The CCB consists of an aggressive behaviour scale with 14 items
rated in terms of frequency, management difficulty, and severity, and a scale for 18 other
types of behaviour rated in terms of frequency and management difficulty. Frequency is
60
measured on a five-point scale rating the occurrence of the behaviour. Severity is a five-point
scale using the degree of tissue damage and nursing or medical attention required as criteria.
Management difficulty is a five-point scale based on the individual rater’s perception of their
own difficulty in managing a challenging situation.
The CCB authors report reliability comparisons that support the use of this measure as
a survey instrument. Inter-rater and test-retest reliability ranged between 76.9% (rs = .702)
and 90.8% (rs = .88) for the aggressive behaviour checklist, and between 74.8% (rs = .682)
and 86.7% (rs = .689) for the other behaviours checklist (Harris et al., 1994). Content validity
was reported by the authors as high, as the main objective of the measure was to identify the
range of challenging behaviours shown by individuals.
The CCB has been used in similar research studies by Jenkins et al., (1997), Bailey et
al., (2006), Mills & Rose, (2011), and Rose et al., (2013). The checklist was adapted for the
purpose of this study, with participants asked to identify how frequently over the last three
months any service user they worked with exhibited each behaviour. The severity scale for
‘aggressive behaviours’ was removed because it was not needed to calculate how many
behaviours a participant perceived to be challenging. Based on the method described by
Jenkins et al. (1997, through personal discussion with CCB author Harris) a behaviour is
challenging when a frequency score is equal to or greater than three and management
difficulty score is equal to or greater than four. In this study participants were asked to rate
each behaviour for frequency and management difficulty, and subsequent scoring identified
the total number of behaviours each participant perceived to be challenging. Total score was
therefore between 0 and 32 behaviours.
2.4.3.3. Organisational Demands. The Staff Stressor Questionnaire (SSQ, Hatton et
al., 1998) contains 33-items assessing potential stressors derived from previous research of
staff stress in services for people with intellectual disability. The 33-items identify
61
organisation demands within seven subscales: lack of staff, lack of resources, bureaucracy,
user challenging behaviour, poor user skills, low-status job, and work-home conflict.
Participants rate on a 5-point Likert scale from ‘not at all’ to ‘a great deal’ the degree to
which they find each item stressful.
The SSQ authors report adequate internal reliability with Cronbach’s alpha of 0.7 or
higher for five of the subscales (not bureaucracy or work-home conflict) and mean inter-item
correlations at the acceptable level between 0.2 and 0.4. Face, construct and criterion-related
validity of the seven SSQ subscales were also supported through the authors’ preliminary
evaluation (Hatton, Rivers, Mason, Mason, Kiernan et al.. 1999). The SSQ has been
identified as a useful tool for providing information about links between potential stressors
and outcome for staff in services for people with intellectual disability (Devereux et al., 2009;
Hatton, Emerson et al., 1999).
2.4.4. Resources. The staff resources investigated were organisational support, social
support, and coping mechanisms.
2.4.4.1. Organisational support. Organisational support was measured using the Staff
Support and Satisfaction Questionnaire (3SQ, Harris & Rose, 2002). This is a 21-item
measure of staff perceptions of support in the workplace which participants rate on a five-
point Likert scale. The questionnaire can be broken down into five sub-scales: role clarity,
coping resources, risk factors, supportive people, and job satisfaction. The 3SQ authors report
the questionnaire showed good test-retest reliability (r = .82), with the data supporting
internal reliability (Cronbach’s alpha of 0.90) and validity (Harris & Rose, 2002). All five of
the subscales from the 3SQ were used in this study to obtain a total organisational support
score of between 21 and 105. The 3SQ has been used to measure intellectual disability staff
perceptions of organisational support and satisfaction in previous studies (Devereux et al.,
2009: Hodgkins et al., 2005; Mascha, 2009).
62
2.4.4.2. Social support. The Social Support Questionnaire Shortened Version (SSQ6,
Sarason, Sarason, Shearin & Pierce, 1987) investigated the number of perceived social
supports in participant’s lives and the degree to which they are personally satisfying. This
questionnaire asks six questions to identify who people can really count on in five situations
such as ‘Who can you really count on to distract you from your worries when you feel under
stress?’ and one question asking ‘who accepts you totally, including both your worst and your
best points?’ Participants are asked to identify the names of support persons for each question
with space to list up to nine people. Participants are then asked to rate the social support
available to them on a scale ranging from ‘very satisfied’ to ‘very dissatisfied.’ This provides
a score for the number of support people listed between 0 and 9 and a satisfaction score of
between 1 and 6. The scores for all six items are summed and then divided by six to get an
average score for support number and support satisfaction.
The SSQ6 authors reported highly satisfactory test-retest reliability, high internal
reliability (coefficient α) ranging between .90 to .93 for number and satisfaction, and good
convergent and divergent validity (Sarason et al., 1987). The SSQ6 explores an individual’s
perception about what people are available to care about them and who would try to help if
help were needed. Sarason et al. (1987) identify this may be the important value of social
support in promoting physical and psychological health compared with the specific function
of social support.
The SSQ6 will be adapted for the purpose of this study with participants asked to
provide a number from 0 to 9 for the number of social supports they have available for each
item instead of asking them to name each person. The SSQ6 has been used in a previous
study investigating burnout and intellectual disability staff social support (Mutkins et al.,
2011).
63
2.4.4.3. Coping mechanisms. The Shortened Ways of Coping (Revised) Questionnaire
(SWC-R, Hatton & Emerson, 1995) was used to investigate how participants cope with
problems at work. The SWC-R was developed from the Folkman and Lazarus (1985) Ways
of Coping (Revised) questionnaire. The SWC-R has 14-items representing thoughts and
actions which can be used to cope with stressful situations that participants rated on a 4-point
Likert Scale from ‘not used’ to ‘used a great deal.’ The scale can be divided into two 7-item
subscales that measure practical coping and wishful thinking.
Hatton and Emerson (1994) examined the reliability and some aspects of validity of the
SWC-R with six different samples of direct care staff in residential services for people with
intellectual disability. The authors reported both subscales to have adequate internal
reliability compared to previous studies using full-length versions of the questionnaire, with
alpha reliability values of .76 for practical coping and .65 for wishful thinking. Mean inter-
item correlations were .31 for the practical coping subscale and .22 for the wishful thinking
subscale, and a mean inter-scale correlation between practical coping and wishful thinking
subscales was found to be .24. The SWC-R was developed specifically with direct care staff
working within residential services for adults with intellectual disabilities, and has been used
as a measure in studies of staff stress and burnout (Devereux, Hastings, Noone, Firth et al.,
2009; Hatton et al., 1995; Hatton, Emerson et al., 1999; Mascha, 2007; Mitchell & Hastings,
2001).
2.4.5. Appraisals. The Maslach Burnout Inventory-Human Services Survey (MBI-
HSS, Maslach, Jackson, & Leiter, 1996) was used to measure personal accomplishment
(appraisal of job satisfaction) and emotional exhaustion (appraisal of job burden). The MBI-
HSS is a 22-item measure of burnout in human services, made up of three scales. A full
description of the MBI-HSS was provided in the introduction but a brief overview is provided
again here. The 9-item emotional exhaustion subscale measures feelings of being emotionally
64
overextended and exhausted. The 8-item personal accomplishment subscale measures
feelings of competence and successful achievement in work.
Participants rated their experience of each item on a 7-point frequency scale from ‘0 =
never’ to ‘7 = everyday.’ Total scores on the two subscales will be reported with higher
scores associated with greater reported feelings of each construct. Data collected on the
depersonalisation subscale will be used descriptively to compare the participants in this study
with normative data of the MBI-HSS and previous research with intellectual disability staff.
The 5-item depersonalization subscale measures unfeeling and impersonal response towards
recipients of one’s service, care treatment or instruction.
The MBI-HSS has been reported to have good test-retest reliabilities, and a factor-
analysis study with direct care staff working with people with intellectual disability reported
Cronbach’s alpha as 0.87 for emotional exhaustion, 0.68 for depersonalisation, and 0.76 for
personal accomplishment (Hastings, Horne, & Mitchell, 2004). The MBI-HSS is considered
the most widely established measure of burnout (Skirrow & Hatton, 2007) and it has been
used in many studies with staff in intellectual disability services (as detailed in the literature
review in sections 1.6.2 and 1.6.3). Permission and licences were obtained from Mindgarden
to use the copyrighted measure for this online study (see Appendix E).
2.4.6. Outcomes. The Positive and Negative Affect Schedule (PANAS, Watson, Clark
& Tellegen, 1988) was used in this study to measure positive affect and negative affect. The
PANAS consists of two 10-item scales, positive affect (PA) and negative affect (NA) and
was developed through factor analyses of 60 positive and negative terms. Internal consistency
reliabilities of the scales are high, with Cronbach’s alpha ranging from .86 to .90 for PA and
.84 and .87 for NA. The two scales have low correlations between them sharing
approximately 1% to 5% of their variance. In terms of related constructs the Beck Depression
65
Inventory (Beck, Ward, Medelson, Mock, & Erbaugh, 1961) was found by the authors to
correlate with the NA scale, and negatively correlate with the PA Scale.
The PA scale has been found to relate to external variables of social activity and diurnal
variation, whereas the NA scale has been found to be significantly related to perceived stress
and does not show circadian pattern (Watson, 1988). The PANAS was used in this study
because it measures both affective components, compared with measures of psychological
well-being that only measure negative affect or depression such as the Beck Depression
Inventory-II (Beck, Steer, & Brown, 1996) and Patient Health Questionnaire-9 (Spitzer,
Kroenke, & Williams, 1999). Participants were asked to rate to what extent they had felt each
item during the past week on a 5-point Likert scale ranging from ‘very slightly or not at all’
to ‘extremely.’
2.4.7. Pilot study. A simple pilot study was conducted to see how support workers
might find navigating the internet survey, whether the instructions and questionnaires made
sense and could be followed without further explanation from the researcher, and how long
the survey would take to complete. Three support workers known to the researcher completed
the survey, all were computer literate and one did not have English as their first language.
The three surveys completed during the pilot study were not used as part of the main study
findings. The three support workers however had the option to participate anonymously in
the study once the survey went live.
All three participants of the pilot study fed back that the survey took approximately 30
minutes to complete, that they could complete and understand the survey without further
instruction. Feedback suggested that the questionnaires made sense and participants were able
to navigate around the survey site. The three participants were able to identify a category of
intellectual disability for the service users they supported. It was not established whether the
participants understood the definitions of the ICD-10 (World Health Organisation, 2010)
66
criteria for mild, moderate, severe, and profound intellectual disabilities. The three
participants were all able to classify their services users into one of these categories based on
their knowledge of the service users and information provided to them within their service
setting.
2.5. Procedure
Participants were recruited through organisations providing services for adults with
intellectual disabilities and online advertisements posted in internet forums. Within
organisations participants were recruited through face to face meetings, study posters placed
on staff noticeboards, and study recruitment letters distributed amongst staff.
The internet survey (see Appendix D) was developed through the survey creator
SmartSurvey (http://www.smartsurvey.co.uk/) an online survey builder. The first page of the
survey provided a brief overview of what the study would involve for the participant. The
second page provided the participant information sheet in different formats. The participant
information sheet was detailed in full on the webpage, a word document copy was also
available to be downloaded and saved, and a recorded verbal version could be listened to.
Participants were asked to read the participant information sheet and tick to state that they
had read this and wanted to continue to the consent form. If people read through the
participant information sheet and did not want to proceed, they could choose the option to
leave the research study through which they would be directed to the study debrief page. The
third page had the consent form where participants were asked to confirm three statements in
order to proceed to the questionnaires. People who did not confirm all three statements were
unable to participate in the survey and were directed to the end of study debrief page.
Participants were then asked to complete the survey measures which took an average
of 30 minutes. Participants had the option to save their completed answers at any time in
order to leave the survey and finish at another time. Through this option participants were
67
asked to provide an email address to which SmartSurvey emailed a web link. After
completing all the survey measures participants were taken to a page which asked them to
select one of two options: to submit their answers to the questionnaires and participate in the
study, or to not submit the answers and withdraw from the study. If the latter option was
chosen the person would be directed to the end of study debrief page. If the participant agreed
to submit their answers to the questionnaire they were directed to a different debrief page
which also provided the web address of where they could read a summary of the results when
the research was completed. Following this, participants accessed the prize draw page where
they were asked to provide a contact name and email address if they wanted to take part.
Participants were provided with the option to not participate in the prize draw and exit the
survey, or tick to state they agreed to take part and exit. Both these options directed
participants to the end of survey debrief page.
2.6. Ethical Considerations
2.6.1. Approval. Ethical approval was obtained in principle from the University of
East Anglia Faculty of Medicine and Health Sciences (UEA FMHS) Ethics Committee prior
to contacting organisations (see Appendix F). The UEA FHMS Ethics Committee required
that written permission from organisations was obtained prior to data collection, and that a
copy of this statement was forwarded on to the Ethics Committee. During three face to face
meetings with organisation representatives study advertising posters and recruitment letters
were provided after verbal permission was obtained, with the author requesting written
permission to be emailed. One organisation did not provide written authorisation after this
and subsequent email requests. Seven organisations provided written permission which was
forward on to the Ethics Committee.
2.6.2. Consent. Participants were provided with three different modes of the
participant information sheet: on page two of the internet survey prior to the consent form, a
68
word copy was available for participants to open and save for their records, and a recorded
spoken version was available to listen to. Hard copies of the participant information sheet
were also provided to organisations along with advertising posters and recruitment letters.
The participant information sheet had the researcher’s telephone and email contact
information, and the research supervisors email contact information, if participants wanted to
ask and have answered any questions about the study. Participants were required to select a
radio button to state that they had read or listened to the participant information sheet and
wanted to proceed to the consent form.
The consent form was on page three of the internet survey prior to the questionnaires.
Participants were required to select the radio button next to three statements confirming that
they had read the participant information sheet and had time to consider the information and
to ask any questions, confirming that they understood that participation was voluntary and
that they would be free to withdraw from the study by not submitting their answers to the
questionnaires, and confirming that they agree to take part in the study. Participants were
asked to select a radio button stating that they had either ticked all three boxes and would like
to proceed to the questionnaires, or they had not ticked all three boxes and therefore would be
unable to participate in the survey.
2.6.3. Confidentiality. Participants were not required to provide any identifying
information about themselves, the organisation they worked for, or the clients they worked
with. The researcher did not have contact with any participants unless the participant chose to
telephone or email to ask questions. Data provided by the participants on the internet survey
was stored by the survey provider SmartSurvey which could only be accessed by the author
through a username and password. Data was subsequently moved from SmartSurvey to a
spread sheet for analysis and stored on the author’s password protected encrypted memory
stick. The data were managed in accordance with the Data Protection Act and after
69
completion of the study are stored for five years within an offsite archiving company used by
the University of East Anglia’s Medical School.
Participants had the option to provide a contact name and email address if they
wanted to take part in the prize draw. The details of participants who entered the prize draw
were stored in a separate file to their survey responses to maintain confidentiality. Once the
total number of participants had been recruited the survey was closed and the prize draw took
place. Two participants were selected at random and were contacted via the email address
provided. The participants were asked to provide the details of an address to which the £50
gift card could be sent along with a receipt and a stamped address envelope. Two people
responded to this email with their address details and were sent their prize in the post. The
names and emails of all the people who entered the prize draw were then deleted. The two
winners were asked to sign the receipt to confirm they had received the voucher and return
this in the envelope provided.
2.6.4. Internet Security. SmartSurvey state on their website that they do not use the
information collected in survey’s in any way. SmartSurvey stated they meet Hacker Safe
certification and they have firewall to prevent hackers from entering their system and
searching files and information. The internet survey was developed using Secure Sockets
Layer (SSL) encryption which protects personal data being entered into the survey.
2.6.5. Debrief. All the people who accessed the internet survey would have been
directed to the end of survey debrief page if they followed the options provided. The debrief
page thanked the person for their interest in the research study and stated that people should
contact the researcher if they has any questions or found completing the survey distressing.
The debrief advised people to contact their general practitioner or NHS Direct if they were
feeling stressed, anxious, depressed, overwhelmed of finding it difficult to cope. Telephone
and online contact details were provided for NHS direct, the Samaritans, and MIND services,
70
and the online information for the local and national IAPT services were provided. The
author did not receive any contact from participants who were in distress after accessing the
survey.
A different debrief page was provided for participants who agreed to submit their
answers to the survey and take part in the study. This debrief page had the same information
detailed above and provided a web address that participants could access in June 2014 to
view a summary of the study results.
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Chapter 3: Results
3.1. Chapter Introduction
This chapter outlines the results from the present study in line with the research
questions and hypotheses. Firstly an explanation of preliminary data analysis is provided.
Descriptive statistics are then reported for the main study variables under the headings of
stressors, resources, appraisal and outcome. The statistical tests used to analyse the main
study hypotheses are presented with the results of each comparison. The method used to
adjust the p-values for multiple comparisons is subsequently outlined and the significant
findings highlighted. Lastly, details of exploratory post hoc analyses are provided along with
a summary of the results.
3.2. Data Analysis
Data analysis was performed using PASW Statistics for Windows Version 18.0 (SPSS
2009). Before hypothesis testing, the main variables were investigated to test their suitability
for parametric statistical analysis. A series of box plot and histograms were developed for the
key variables to explore distribution (plots can be found in Appendix G). One-sample
Kolmogorov-Smirnov tests were also used to ascertain whether each variable was normally
distributed.
Using these plots outliers were found on the ‘challenging behaviour’ scale (Participants
No. 19, 26, 28, 32, 36, 38), ‘social support satisfaction’ scale of the SSQ6 (Participants 16,
17, 19, 27, 30, 32, 36 and 45), ‘depersonalisation’ of the MBI-HSS (Participant No.34) and
‘negative feeling’ of the PANAS (Participant No.15). A floor effect of the data was identified
on the ‘depersonalisation’ scale and for ‘number of challenging behaviours’. Large numbers
of participants scored zero (n=18 and n=30 respectively) which had positively skewed the
data. The ‘depersonalisation’ data was planned to be used only for descriptive purposes and
not analysis therefore no alterations were required. Winorizing the data reduces bias and
72
improves accuracy by replacing outliers with the next highest score that was not an outlier
(Field, 2013). It was believed that changing the outliers of the challenging behaviour data
would not alter the distribution of the data but leaving them in might bias the results in favour
of the hypothesis. The decision was made to categorise ‘number of challenging behaviour’
into ‘yes’ and ‘no’ groups and to compare the group means instead of undertaking
correlational analysis.
Whilst scoring the SSQ6 the ‘Social support satisfaction’ scale was found to have five
negative scores which were anomalies due to incorrect completion of the survey by five
participants. When these five data were removed the box plot showed two outliers
(Participants No 16 and 36) and the data deviated from normal D(42) = .207, p < .001, with a
significant positive skew, zskewness = 4.334, p < .001. The SSQ6 has two subscales therefore it
was decided to drop ‘social support satisfaction’ from further analyses and use only the
‘social support number’ to measure the main variable of social support. When the outlier on
the ‘negative scale’ was replaced using the winorizing method explained above the
distribution remained deviated from normal, therefore the outlier was left and non-parametric
tests were used.
Through looking at the plots and Kolomogorov-Smirnov tests the ‘wishful thinking’
subscale of the SWC-R deviated significantly from normal D(47) = 0.194, p < .001. Both the
‘emotional exhaustion’ scale of the MBI-HSS and ‘negative affect’ scale of the PANAS were
negatively skewed and deviated significantly from normal D(47) = .178, p = .001 and D(47)
= .045, p = .045 respectively. Transformation of data can combat problems with normality
and linearity (Field, 2013) in order to reduce bias. Data would need to be transformed on both
scales to identify a relationship between the variables. As emotional exhaustion is a study
variable in five of the comparisons this would mean transforming most of the data. It was
73
decided to leave all the data as it was and to use non-parametric tests where violations of
assumptions had occurred.
The ‘staff stressor’ and ‘organisational support’ subscales showed some positive
(0.490) and negative (-0.640) skew respectively. The skewness values were converted into z-
scores and compared to a normal distribution value of 0. Both z-scores were found to be less
than 1.96, therefore not significant. These scales along with ‘practical coping’ on the SWC-R,
‘job satisfaction’ on the 3SQ, ‘social support number’ on the SSQ6, ‘personal
accomplishment’ on the MBI-HSS, and ‘positive affect’ on the PANAS were all identified as
meeting the assumptions for parametric tests.
3.3. Descriptive Statistics
Descriptive statistics for each measure were conducted and can be found in Table 3.1.
Means, standard deviations, median and inter-quartile range values are provided for all the
main variables. Reporting the median is more appropriate than the mean for data that is not
normally distributed. Where possible descriptive statistics and internal consistency of the
scales found in this study were compared with normative data previously collected for each
measure.
3.3.1. Stressors. The categories of intellectual disability were not evenly distributed
with higher percentages of participants identifying the people they supported as having a
severe (36.2%) or moderate (34.0%) intellectual disability and smaller percentages of
profound (21.3%) and mild (8.5%). It was decided to group the categories into two, mild to
moderate intellectual disability (n = 20) and severe to profound intellectual disability (n = 27)
for further analyses. Following the criteria of what constitutes a behaviour as challenging on
the CCB (frequency equal to or greater than 3 and management difficulty equal to or greater
than 4) one-third of participants perceived the behaviours of adults they supported as
challenging. Organisational demands were identified by the total score of the SSQ, which
74
Table 3.1.
Descriptive statistics for the main study variables.
Measure n
%
Category of Intellectual
Disability
Mild
Moderate
Severe
Profound
4
16
17
10
8.5
34.0
36.2
21.3
Checklist of Challenging
Behaviour
Number of challenging
behaviours
0
1
2
3
4
5
6
7
15
Experiences challenging
behaviour
Yes
No
31
4
3
3
1
1
1
2
1
16
31
66.0
8.5
6.4
6.4
2.1
2.1
2.1
4.3
2.1
34.0
66.0
Measure n
M SD Median Interquartile
Range
Staff Stressor Questionnaire 47 65.64 23.33 63.0 38.0
Staff Support and Satisfaction 47 79.60 17.48 81.0 25.0
Shortened Ways of Coping - R
Wishful thinking 47 12.13 4.51 11.0 8.0
Practical coping 47 19.96 3.98 20.0 6.0
SSQ6
Social support number 47 3.85 1.86 3.67 2.83
Social support satisfaction 42 2.08 1.12 1.92 5.0
MBI-HSS
EE scale 47 18.33 12.84 15.0 21.0
DP scale 47 3.05 3.99 1.0 6.0
PA scale 47 36.62 6.11 37.0 10.0
PANAS
Positive scale 47 34.98 7.62 35.0 11.0
Negative scale 47 16.74 6.00 16.0 8.0
75
ranged from 35 to 113 (out of a maximum 165), with higher scores signifying greater
demands. The SSQ measure was found to have high internal consistency with Cronbach’s
alpha value of .94 across the 33 items.
3.3.2. Resources. Organisational support was found to vary with participants
reporting scores of 34 to the maximum of 105 on the 3SQ, with higher scores identifying
higher staff support and satisfaction. On the SSQ6 participants identified having on average
three or four social supports. With regard to ways of coping, both subscales of the SWC-R
had good internal consistency. Compared with the psychometric properties reported by
Hatton and Emerson (1995) Cronbach’s alpha values were higher for the wishful thinking
subscale (.81 compared with .65) and lower for practical coping (.74 compared with .76).
Participant average score on the ‘wishful thinking’ scale (M = 12.13, SD = 4.51) was lower
than the average score on the ‘practical coping’ scale (M = 19.96, SD = 3.98).
3.3.3. Appraisals. The mean scores (and standard deviations) for personal
accomplishment as measured by the MBI-HSS was 36.62 (6.11) for ‘personal
accomplishment’. Due to the data on the ‘emotional exhaustion’ subscale not meeting the
assumptions for parametric tests the appropriate descriptive statistic to report is a median of
15 (interquartile range = 21). The current study found excellent internal consistency for the
‘emotional exhaustion’ subscale (α = .91), with acceptable levels for ‘personal
accomplishment’ (α = .67).
In terms of job burnout participants’ scores on the three subscales of the MBI-HSS
could be compared with the normative data collected by Maslach and Jackson (1981) and
Skirrow and Hatton (2007). The means of the emotional exhaustion and depersonalisation
subscales will be reported in order to compare it with the normative data on the MBI-HSS.
For this purpose the mean (and standard deviation) was 18.33 (12.84) for ‘emotional
exhaustion’ and 3.05 (3.99) for ‘depersonalisation’. The means on the three subscales in this
76
study were similar to those in the meta-analysis of studies investigating intellectual disability
staff reported by Skirrow and Hatton (2007) of 17.4, 33.8, and 5.0 for ‘emotional exhaustion’,
‘personal accomplishment’ and ‘depersonalisation’ respectively. Similarly, the present
findings were lower than but within one standard deviation of the normative mean values
reported by Maslach et al. (1996) of 21.0 (10.8) for ‘emotional exhaustion’, 34.6 (5.9) for
‘personal accomplishment’, and 8.7 (7.1) for ‘depersonalisation.’
Maslach et al., (1996) provided scoring criteria for each of the three dimensions to
signify ‘high,’ ‘moderate’ and ‘low’ levels of burnout. Using these criteria, 27.8% of the
sample in the present study reported high levels of burnout on ‘emotional exhaustion’, 2.1%
high levels of burnout on ‘depersonalisation’, and 25.5% high levels of burnout on ‘personal
accomplishment.’ The majority of participants in this study were categorised as having low
levels of burnout on ‘emotional exhaustion’ (59.6%) and low levels of burnout on
‘depersonalisation’ (85.1%), with 42.6% experiencing low levels of burnout on ‘personal
accomplishment’.
3.3.4. Outcomes. With regard to the PANAS, the mean positive affect scale score was
34.98 (SD = 7.62) and the mean negative affect scale score was 16.74 (SD = 6.00). These are
broadly similar to the normative data reported by Watson et al. (1988) for feelings over the
past two weeks: 32.0 (SD = 7.0) and 19.5 (SD = 7.0) for the respective scales. Watson et al.’s
(1988) normative data was from a sample of psychology undergraduates, though Thomas and
Rose (2010) reported similar mean scores for their sample of intellectual disability staff with
mean ‘positive affect’ 35.42 (SD = 35.42) and mean ‘negative affect’ 16.36 (SD = 6.70). The
negative affect scale violated the assumptions of normality therefore the median was 16
(interquartile range = 8). Both scales were found to have good internal reliability in this study
with Cronbach’s alpha values of .86 for ‘positive affect’ and .78 for ‘negative affect’.
77
3.4. Research Hypotheses
The study hypotheses were explored using Mann-Whitney U tests, Pearson and
Spearman correlations. For the correlation statistics bias corrected and accelerated bootstrap
95% confidence intervals are reported in square brackets. Boxplots and scatterplots were
developed for the analysis of the main variables and can be found in Appendix H.
Hypothesis 1: Severity of intellectual disability is associated with emotional
exhaustion. Participants who supported adults with severe-profound intellectual disabilities
(Mdn =11.0) had significantly higher levels of emotional exhaustion than participants who
supported adults with mild-moderate intellectual disabilities (Mdn = 25.0), U = 382.5, z =
2.42, p = .015, r = .35.
Hypothesis 2: Number of challenging behaviours are associated with emotional
exhaustion. Participants who experienced one of more behaviours as challenging (Mdn =
28.0) had significantly higher levels of emotional exhaustion than participants who did not
experience behaviours as challenging (Mdn = 13.0), U = 150.50, z = -2.192, p = .028, r = -
.32.
Hypothesis 3: Organisational demands are associated with emotional exhaustion.
Organisational demands were significantly related to emotional exhaustion rs(47) = .690 BCa
CI [.502, .818], p < .001 (2-tailed). Higher levels of organisational demands were associated
with higher levels of burnout with a large positive correlation.
Hypothesis 4: Practical coping is associated with personal accomplishment. No
association was found between practical coping and personal accomplishment SWC-R r(47)
= .021, BCa CI [-.276, .303], p = .889 (2-tailed).
Hypothesis 5: Wishful thinking is associated with emotional exhaustion. Wishful
thinking was significantly related to emotional exhaustion rs (47) = .677 BCa CI [.426, .831],
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p < .001 (2-tailed). The more frequently participants used wishful thinking coping strategies
the higher the level of burnout, with a large correlation.
Hypothesis 6: Organisational support is associated with emotional exhaustion.
Organisational support was significantly related to emotional exhaustion rs(47) = -.505 BCa
CI [-.723, -.210], p = < .001 (2-tailed). Lower levels of organisational support were
associated with higher levels of burnout, with a large correlation.
Hypothesis 7: Social support is associated with personal accomplishment. Number
of social supports was significantly related to personal accomplishment r (47) = .335 BCa CI
[.065, .556], p = .021 (2-tailed). A medium correlation was found, the higher the levels of
social support participants had the higher job satisfaction.
Hypothesis 8: Personal accomplishment is associated with positive affect. Personal
accomplishment was significantly related to positive affect r(47) = .628 BCa CI [.401, .780],
p < .001 (2-tailed). A large correlation was found, the higher a participants level of job
satisfaction the higher their positive affect.
Hypothesis 9: Emotional exhaustion is associated with negative affect. Emotional
exhaustion was significantly associated with negative affect rs(47) = .648 BCa CI [.433,
.806], p < .001 (2-tailed). A large positive correlation was found, the higher the level of
participant burnout the higher their negative affect.
3.5. Adjusted p-values for Multiple Tests
During the analysis nine statistical inferences were made, with multiple simultaneous
comparisons increasing the likelihood of incorrectly rejecting the null hypothesis. Adjusting
the p-value compensates for the number of tests conducted. The adjusted p-value for a
particular hypothesis within a collection of hypotheses is the smallest overall significance
level at which the particular hypothesis would be rejected (Wright, 1992). During a priori
calculations of sample size Bonferonni’s correction was used. The p-value can be adjusted
79
post-hoc using Holm’s procedure (Holm, 1979) or the Benjamini-Hochberg false discovery
rate (Benjamini & Hochberg, 1995) which modify the Bonferroni procedure to increase
power. Holm’s procedure is less conservative than Bonferroni’s, similar in its sequential
rejection of p-values, but maintaining the experimentwise error rate at α (Wright, 1992). The
false discovery rate (FDR) is a post hoc maximising procedure that controls for the
experimentwise error rate by advancing Bonferonni-type procedures with the potential to
gain power (Benjamini & Hochberg, 1995).
Table 3.2.
Holm’s adjusted p-value for multiple tests.
i Hn pi pHolm Null
Hypothesis
(H0)
Significance
1 H3 .001 .0056 Rejected Significant
2 H5 .001 .0056 Rejected Significant
3 H6 .001 .0056 Rejected Significant
4 H8 .001 .0056 Rejected Significant
5 H9 .001 .0056 Rejected Significant
6 H1 .015 .013 Not significant
7 H7 .021 .017 Not significant
8 H2 .028 .025 Not significant
9 H4 .889 .05 Not significant
Note. Hn: Study hypothesis number; pi: Unadjusted p-value; pHolm: Adjusted p-value based on
Holm’s procedure.
For this study the Holm’s procedure was used post hoc. A brief description of how
Holm’s procedure was conducted on the p-values obtained in this study will now be given.
The p-values from the inferential statistics were listed from smallest to highest and numbered
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(i), as shown in Table 3.2. A Holm adjusted p-value (pHolm) was calculated by α/(n – i + 1).
As an example for i1, pHolm = .05/(9 – 1 + 1) which equals .0056. This adjusted p-value was
then compared with the original p-value to see whether pi ≤ pHolm. If pi was less than pHolm the
null hypothesis was rejected. In Holm’s sequentially rejective procedure where pi values are
the same, pHolm remains the same (e.g. p1 to p5 are all .001 therefore pHolm remains .0056).
Using Holm’s procedure the nine inferential statistics found in this study were compared with
the adjusted p-value and five remained significant.
3.6. Explorative Post-hoc Analysis.
To limit the number of comparisons made, there were relationships between variables
in the staff well-being model of interest that were not included in hypothesis-testing. These
relationships were analysed post hoc, using Bonferonni adjusted p-values, to explore whether
they should be investigated in future research studies. The relationships were between
appraisals and outcomes: personal accomplishment and negative affect; emotional exhaustion
and positive affect; personal accomplishment and emotional exhaustion; and positive affect
and negative affect. The four post hoc comparisons increased the total number of
comparisons made to 13. Adjusted p-values using Bonferonni’s correction meant the level of
significance for these four comparisons was α = .0038.
Spearman correlations were used and no association was found between personal
accomplishment and negative feelings rs(47) = -.248, BCa CI [-.511, .049], p = .092 (2-
tailed), between emotional exhaustion and positive feelings rs(47) = -.282, BCa CI [-.571,
.032], p = .055 (2-tailed), and between positive feelings and negative feelings rs(47) = -.214,
BCa CI [-.489, .115], p = .148 (2-tailed). A significant association was found between
emotional exhaustion and personal accomplishment rs(47) = -.479, BCa CI [-.702, .187], p <
.001 (2-tailed), with a moderate negative correlation.
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3.7. Results Summary
Analysis of the collected data found five significant relationships between main study
variables: organisational demands was associated with emotional exhaustion, wishful
thinking was associated with emotional exhaustion, organisational support was associated
with emotional exhaustion, personal accomplishment was associated with positive affect, and
emotional exhaustion was associated with negative affect. Four further relationships were
explored post hoc. Inferences will now be drawn from the data and the results compared with
those obtained in previous studies.
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Chapter 4. Discussion
4.1. Chapter Introduction
This chapter discusses the results found in the present study for each research
question and hypothesis. Strengths and weaknesses about the theoretical model, internet
survey, measures, sample, and statistical analysis used in this study are identified. Both
theoretical and clinical implications of the research findings are highlighted before ideas for
future research are suggested. Finally, conclusions are drawn from the presented information
through a summary of the study aim, research questions, and findings.
4.2. Summary of Results
The aim of the present study was to explore nine hypothesised relationships between
staff well-being variables along two distinct pathways through which staff appraisals of
personal accomplishment and emotional exhaustion are associated with different dimensions
of well-being. As shown in Figure 4.1, five of the nine hypothesised relationships between
variables were significant, with medium to large correlations. The results will be discussed as
individual hypothesis tests and related to previous findings and the theoretical model.
4.3. Research Questions and Hypotheses
4.3.1. Are there associations between stressors and appraisals as conceptualised
in the staff well-being model? The first three study hypotheses predicted relationships
between stressors and the secondary appraisal of job burden, conceptualised as emotional
exhaustion. Three stressors were predicted to have positive relationships with emotional
exhaustion: intellectual disability, challenging behaviour, and organisational demands.
4.3.1.1. Hypothesis 1. Severity of intellectual disability is associated with emotional
exhaustion. Participants who supported adults with severe or profound intellectual
disabilities reported on average higher levels of emotional exhaustion than participants
supporting adults with mild or moderate intellectual disabilities but the difference was not
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significant. This differs to the finding of Gray-Stanley and Muramatsu (2011) who used a
study specific 7-item Likert scale to measure ‘client disability,’ incorporating levels of client
functioning, mobility and intellectual abilities.In the present study participants were not asked
about functioning and mobility, they only rated their perception of service user intellectual
disability. Participants were asked to rate intellectual disability as mild, moderate, severe or
profound in line with categories defined in ICD-10 (World Health Organisation, 2010). These
categories were then grouped into two for the purpose of analysis due to small numbers in the
mild and profound categories.
Figure 4.1. Significant relationships found. Original in colour.
It could be suggested that participant selection of the category was not correct to ICD-
10 criteria, with people differing in their view of what categorises mild compared with
moderate, or severe compared to profound. Unless participants knew of exact diagnosis each
r = .628, p < .001
Wishful
thinking
Personal
accomplishment
Positive
affect
OUTCOMES APPRAISALS STRESSORS and RESOURCES
Negative
affect
Organisational
support
Organisational
demands
Emotional
exhaustion
rs = .648, p < .001 rs = .677, p < .001
rs = .69, p = .001
rs = -.505, p < .001
84
service user they supported had received, it’s possible they were making a decision based on
their own perception of service user’s abilities and support needs.
4.3.1.2. Hypothesis 2: Number of challenging behaviours are associated with
emotional exhaustion. Participants who perceived that behaviours of the adults they
supported were challenging had on average higher levels of emotional exhaustion than
participants who did not perceive behaviours as challenging but the difference was not
significant. This finding is comparable to that of Rose and Rose (2005) who found no
significant difference using a similar method of splitting participants into two groups (‘very
high and high’ or ‘low and very low’) depending on their self-reports of aggressive behaviour
on the Aberrant Behaviour Checklist. Mutkins et al. (2011) used a 2-item Likert scale to ask
participants about frequency and type of challenging behaviour and did not find an
association between this and burnout.
This finding differs to results found by other studies investigating intellectual
disability staff burnout and challenging behaviours measured by the same questionnaire the
Checklist of Challenging Behaviour (Mills & Rose, 2011), the Aberrant Behaviour Checklist
(Chung & Harding, 2009), and a 6-item Likert scale measuring client aggression (Hensel et
al., 2012). A large proportion of the sample in this study (66%) did not perceive any
behaviours of service users as challenging. Choices made through the Checklist of
Challenging Behaviour could have identified participant’s perception of what they personally
find challenging as opposed to what an independent observer might rate objectionably as
challenging as defined by the Checklist’s criteria. In line with Howard et al.’s (2009)
suggestion that staff’s perception of their ability to manage challenging behaviour mediates
between the stressor and burnout, it’s possible that participants were exposed to behaviours
but felt they could manage them.
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4.3.1.3. Hypothesis 3: Organisational demands are associated with emotional
exhaustion. The number of organisational demands was significantly associated with
appraisals of job burden, with higher levels of staff stressors positively predicting higher
levels of emotional exhaustion. This supports the result of Devereux, Hastings, Noone, Firth
et al., (2009) who found total score on the staff stressor questionnaire to positively predict
emotional exhaustion. Other studies have found associations between burnout and ‘work
stress’ dimensions of work conflict (Gill-Monte & Peiro, 1997; Vassos & Nankervis, 2012)
work overload and low decision-making participation (Gray-Stanley & Muramatsu, 2011),
low job status, bureaucracy, job control, role ambiguity, and influences over work decisions
(Vassos & Nankervis, 2012).
4.3.1.4. Discussion of the first research question. In regards to the research question
there was an association between the stressor of organisational demands and appraisal of
emotional exhaustion. Organisational demands were found to be a stressor that put staff
supporting adults with intellectual disabilities under pressure. Pressure is identified as normal
and necessary to motivate people to undertake tasks and seek achievement (Grimshaw, 1999).
When this pressure becomes too much, as identified in this study, it can trigger secondary
appraisals. Higher levels of perceived organisational demands were associated in the present
study with secondary appraisals of job burden in the form of higher levels of emotional
exhaustion.
According to cognitive-behavioural theory of work stress, participants who reported
higher levels of organisational demands may be perceiving demands of their job role as a
threat (Lazarus & Folkman, 1984). This threat may have affected participants own evaluation
of the quality of how they support adults with intellectual disabilities leading to an increase in
job burden. Greater severity of client intellectual disability, and experiencing client
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behaviours and interpreting them as challenging were not found to be stressors associated
with secondary appraisals of job burden.
4.3.2. Are there associations between resources and appraisals as conceptualised
in the staff well-being model? Four hypotheses predicted relationships between
organisational and personal resources and appraisals of job satisfaction and job burden.
Resources were either organisational: staff support and satisfaction, or personal: social
support, wishful thinking and practical coping strategies. Social support and practical coping
were predicted to relate to personal accomplishment, whilst organisational support and
wishful thinking were predicted to relate to emotional exhaustion.
4.3.2.1. Hypothesis 4. Practical coping is associated with personal accomplishment.
With regard to hypothesis 4, practical coping was not associated with personal
accomplishment. This result differs from the findings of Devereux, Hastings, Noone, Firth et
al., (2009) who found practical coping measured using the same SWC-R scale a positive
predictor of personal accomplishment. Mitchell and Hastings (2001) found ‘adaptive’
strategies, a dimension of the COPE inventory (Carver, Scheier & Weintraub, 1989)
including both practical and emotion-focused coping strategies, were predictive of increased
feelings of personal accomplishment. Participants in the present study did use practical
coping techniques but these were unrelated to appraisal of job satisfaction. This is similar to
the result of Mascha (2007) who found practical coping was unrelated to factors of job
satisfaction and personal accomplishment. The sample size of the present study and the study
by Mascha (2007) were both small (N = 36 and 47 respectively). Though both correlation
coefficients reported were small (.08 and .02 respectively) meaning it is unlikely a larger
sample would have increased the power of this result.
4.3.2.2. Hypothesis 5. Wishful thinking is associated with emotional exhaustion.
With regard to hypothesis 5, the more frequently participants used wishful thinking coping
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strategies the higher the level of emotional exhaustion. This supports pervious research by
Devereux, Hastings, Noone, Firth et al., (2009) who found wishful thinking measured using
the SWC-R scale a positive predictor of emotional exhaustion. The wishful thinking subscale
of the SWC-R measure includes ‘I wish I could change what has happened,’ ‘I wish I could
change how I feel,’ and ‘I wish that the situation would go away or somehow be over with.’
Wishful thinking has been identified in a range of population samples to be positively
associated with an unsatisfactory outcome of stressful encounters (Folkman et al., 1986), and
maladaptive outcomes such as distress, depression and anxiety (Hatton & Emerson, 1995).
4.3.2.3. Hypothesis 6. Organisational support is associated with emotional
exhaustion. Participants perceiving lower levels of organisational support had significantly
higher levels of emotional exhaustion. This supports the finding of Mascha (2007), Chung
and Corbett (1998) and Mutkins et al., (2011). Using the same measure (3SQ) as the present
study Mascha (2007) reported low satisfaction with supervision and role clarity associated
with higher emotional exhaustion. Chung and Corbett (1998) also found emotional
exhaustion positively correlated with staff feeling in need of support from management.
Mutkins et al. (2011) found lower perceived organisational support, measured by an 8-item
survey, significantly associated with higher emotional exhaustion.
4.3.2.4. Hypothesis 7. Social support is associated with personal accomplishment.
With regard to hypothesis 7, social support was not associated with personal accomplishment.
This result compares with the finding of Aitken and Schloss (1994) who found social support
was not associated with personal accomplishment. Aitken and Schloss (1994) found social
support was related to other personal resources such as recreation and self-care. The present
study result differs to the finding of Mutkins et al. (2011) who used the same measures as the
present study (SSQ6 and MBI-HSS) and found higher numbers of social support significantly
associated with higher levels of personal accomplishment. Mutkins et al. (2011) reported a
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correlation coefficient (no mention of the statistical test used) of .31 (p < .01, N = 80). The
present study found a similar correlation r(47) = .34 but the small sample meant this effect
size did not have enough power to reach statistical significance. In the present study social
support was measured only by the ‘number’ scale of the SSQ6 as the ‘satisfaction’ scale data
was dropped due to the data being skewed. It could be argued that participant’s satisfaction
with social support might have been a better measure of social support as a resource, with
Mutkins et al., (2011) finding significant negative correlations between support satisfaction
and measures of stress and depression.
4.3.2.5. Discussion of the second research question. Secondary appraisals of job
satisfaction and job burden were hypothesised to be associated with organisational and
personal resources. It appears that perception of organisational support is associated with
staff evaluations of their own work and the secondary appraisals they report. According to a
cognitive-behavioural model of work stress coping strategies are believed to influence how a
person appraises stressful situations. With practical coping strategies associated with
appraising stress as a challenge, and emotion-focused coping associated with appraisals of
threat (Lazarus & Folkman, 1984). In this study staff using practical coping strategies to cope
with problems in their work was not associated with secondary appraisals of job satisfaction.
Using emotion-focused coping strategies of wishful thinking to cope with problems at work
was associated with the secondary appraisal of job burden.
4.3.3. Are there associations between appraisals and outcome as conceptualised
in the staff well-being model? Two relationships were hypothesised between secondary
appraisals of job satisfaction and job burden, and outcomes of positive and negative feelings.
Appraisals of personal accomplishment were predicted to relate to positive affect, and
appraisals of emotional exhaustion were predicted to relate to negative affect.
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4.3.3.1 Hypothesis 8. Personal accomplishment is associated with positive affect.
Personal accomplishment was associated with positive affect. Participants who reported
higher levels of personal accomplishment on the MBI-HSS reported higher levels of positive
affect. This supports the findings of other studies who have investigated personal
accomplishment using the MBI-HSS and positive affect using the Positive Affect and
Negative Affect scale (Hickey, 2014; Thomas & Rose, 2009). Similar to the results of
Hastings and Horne (2004) participants were found to experience positive perceptions about
their work, in this study personal accomplishment was conceptualised as the perception of
gains and satisfaction with one’s job. In line with Lawton et al.’s (1991) two factor model of
caregiving appraisal and psychological well-being, appraisals of job satisfaction in the
present study were associated with the positive dimension of well-being.
4.3.3.2. Hypothesis 9. Emotional exhaustion is associated with negative affect. With
regards to hypothesis 9, emotional exhaustion was found to be associated with negative
affect. Participants in this sample that reported higher levels of emotional exhaustion on the
MBI-HSS also reported higher levels of negative feelings on the negative scale of the
Positive Affect and Negative Affect scale. This result supports the findings of many studies
investigating burnout in intellectual disability staff. Burnout in terms of higher emotional
exhaustion is associated with negative emotions and symptoms of distress such as anxiety
and depression (Aitken & Schloss, 1994; Hickey, 2014; Mills & Rose, 2011; Mutkins et al.,
2011; Rose et al., 2004; Thomas & Rose, 2009). In line with Lawton et al.’s (1991) two
factor model of caregiving appraisal and psychological well-being, appraisals of job burden
in the present study were associated with the negative dimension of well-being.
4.3.3.3. Discussion of the third research question. Two parallel processes were
hypothesised to occur depending on the staff member’s secondary appraisal. In this study
staff appraisal of personal accomplishment was associated with positive affect and staff
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appraisal of emotional exhaustion was associated with negative affect. Psychological well-
being has been conceptualised as two independent dimensions of positive affect and negative
affect (Bradburn, 1969) and work satisfaction has also been proposed to follow a similar
model with ‘dissatisfiers’ and ‘satisfiers’ (Herzberg, 1959, as cited by Bradburn, 1969). In
support of these theories staff in this study who reported higher levels of personal
accomplishment also reported higher levels of positive feelings. Whilst staff who reported
higher levels of emotional exhaustion also reported higher levels of negative feelings.
Analyses were undertaken post hoc to explore whether these two relationships were
distinct. The results of the post hoc analysis suggested that personal accomplishment was not
associated with negative affect and emotional exhaustion was not associated with positive
affect. In line with Lawton et al.’s (1991) two-factor model the two secondary appraisals
were associated with the two different dimensions of well-being. These results show that staff
experience both job appraisals and outcomes. The higher the level of secondary appraisal the
higher the associated dimension of affect.
4.4. Strengths and weaknesses of the study
4.4.1. Theoretical model. A strength of the current study was that it was explicitly
based on theory, using the structure of Lawton et al.’s (1991) two-factor model of caregiving
appraisal and psychological well-being and the cognitive-behavioural model of work stress.
Conceptualised from these two theoretical models the staff well-being model was developed
for the purpose of this study to explore variables previously identified in intellectual
disability staff research on stress and burnout, and hypothesised relationships between them.
This is a strength and means the results could contribute to confirmatory proof of the
underlying processes of both theoretical models. Structural equation modelling is a powerful
statistical technique that would allow exploration of the variables to establish the goodness of
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fit of the hypothesised staff well-being model. A sample of over 200 participants would be
required to undertake structural equation modelling.
The staff well-being model was used for conceptual purposes, to visualise the
hypothesised relationships between variables labelled ‘stressors,’ ‘resources,’ ‘appraisals’ and
‘outcome.’ The number of comparisons made between variables in the model had to be
limited due to the size of the study sample, to decrease the likelihood of Type I errors. As
such there were relationships of interest that were not tested, shown in Figure 4.2.
Figure 4.2. Hypothesised relationships not explored in the current study.
Exploration of four of these relationships post hoc suggested these could be
investigated in future studies through a hypothesis-testing approach. In order to explore
further, the two hypothesised pathways between appraisals and outcomes could be
investigated to see whether they are parallel and distinct. The relationships between appraisal
of job satisfaction and negative affect, and between appraisal of job burden and positive
affect could be tested, as well as relationships between the two appraisals, and between the
Personal
accomplishment
Intellectual
disability
Positive
affect
OUTCOMES APPRAISALS STRESSORS
Challenging
behaviour
Negative
affect
Organisational
demands
Emotional
exhaustion
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two outcomes. Other relationships of interest would be between stressors and the appraisal of
personal accomplishment, to explore which aspects of support work might contribute to
perceived satisfaction with one’s job. Hensel et al. (2012) found that greater levels of
exposure to aggressive behaviour the higher the sense of personal accomplishment, and it
would be interesting to explore whether organisational demands are associated with personal
accomplishment. Also to see how resources might mediate the relationship between
organisational demands and the appraisal of emotional exhaustion.
4.4.2. Use of an internet survey. Use of an internet survey was a strength and
limitation of this study. An online survey meant anonymity of participation was assured
which was important due to the sensitive nature of the topic. Online methods have been found
to allow greater disclosure than offline methods because of perceived anonymity (Ayling &
Mewse, 2009). An online survey also removed barriers between recruitment and
geographical location. This meant that organisations who provided permission to take part in
the study could advertise the survey in services spread across the United Kingdom. The
survey was also advertised through internet forums online, a cost- and time-effective method
of reaching people. Online advertising allowed an easy method of communicating with
individuals who could reply directly to the post to ask questions or clarify queries about
selection criteria. The cost of hosting the survey through SmartSurvey was less than printing
and postage costs of a paper-based survey. The online provider reduced the time taken to
score measures by assigning pre-specified values to each answer and transposing the scored
values efficiently into a spreadsheet for further analysis. This reduced the likelihood of
human errors caused by the manual transformation of data from paper questionnaires into a
data spreadsheet and manual scoring procedures.
A limitation of using an internet survey was the increased number of barriers between
an individual hearing about the study through their organisation, by seeing an advertising
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poster or receiving a recruitment letter, and accessing the survey on their home computer.
Barriers such as misunderstanding the purpose of the study or what participation involved,
not having a computer or the internet at home to use, limited computer skills, forgetting about
the study, and not wanting to do something associated with work at home or outside of
working hours. These barriers might have been removed if the survey had been paper based
with individuals able to read through the questionnaires and fill them in immediately if
interested.
Yetter and Capaccioli (2010) found experimentally that survey delivery to education
staff affected response rates with participants significantly more likely to complete paper
surveys than online surveys. Though Weigold, Weigold and Russell (2010) found in a similar
study with college students equivalence between paper versus internet conditions for self-
report survey-based measures comparison study. These results may be population specific
with college students more familiar with technology than education staff. As yet there has not
been a similar comparison study of paper and internet surveys with intellectual disability
staff. Research has also suggested that male study participants are more likely than females
to complete web surveys (McCabe, Couper, Cranford, & Boyd, 2006) and web-based
approaches may be less appropriate with older populations (Klovning, Sandvik, & Hunskaar,
2009). Intellectual disability services are known to be composed of greater numbers of female
workers, with a variety of ages including older populations.
Barriers could have been removed through face to face contact with potential
participants with specific instructions given about the purpose of the study and availability to
answer any questions immediately. Meetings the researcher attended with groups of staff
during their working hours were perceived to go successfully with people asking questions
and showing interest. It is impossible to know whether this translated into people then
accessing the survey due to the anonymity of participants. Participants in an online study are
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more likely than those offline to become disengaged and drop out (Tates et al., 2009). It has
also been recognised by Frisoli (2010) that participants of an online study might become
distracted and engage in other activities whilst taking part in the study.
Muñoz-Leiva, Sánchez-Fernández, Montoro-Ríos, and Ibáñez-Zapata (2009)
investigated how personalised invitations to take part in a study and the frequency of
reminders about the study affected participation. Both of these methods significantly
increased response rates and this reported to be in line with the theory of social exchange.
This option could have been explored in this study when meeting with staff teams, giving
them the option to provide an email address of choice and provide consent to be contacted by
this method with information about the study. This could have been considered further
during the planning stage of this study. Considering whether intellectual disability staff
would be an appropriate population to survey online and whether they have access to work
email accounts. Making use of internal email networks could have distributed information
about the survey to higher numbers of perspective participants and removed some of the
barriers mentioned above.
Another limitation of the online study was an increased likelihood of people outside
of the sampling criteria completing the survey and biasing the results. Wilkerson, Iantaffi,
Grey, Bockting, and Rosser. (2014) provide a detailed report into the considerations
researchers should make when developing online data collection methods. The report
focusses on qualitative data collection though there are many parallels amongst their
recommendations for quantitative methods. Wilkerson et al. (2014) provide two decision-
making checklists appended to their article that would have been useful to read before
undertaking this internet-based study. The checklists would be a useful tool for any
researcher to look at before proposing online data collection methods.
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4.4.3. Measures. A strength of the measures used in this study was the fact that they
had all been used in previous research investigating burnout with intellectual disability staff.
Using structured questionnaires instead of study-specific Likert scales increased the
reliability and validity of study data, and meant direct comparisons could be made with
previous study findings and normative data. Internal consistency through Cronbach alpha,
and face, content, construct and factorial validity data of each measure could be considered
and presented to show it’s suitability for use in this study to test the variable under
investigation (Meltzoff, 1998). Tests of internal consistency were undertaken for each
subscale used in the present study with excellent or acceptable levels found.
A limitation of using self-report measures is the potential source of self-serving bias
with participant distortions of self-perception (Meltzoff, 2008). The present study was
interested in exploring participant perceptions of working with adults with intellectual
disabilities, with all the study variables open to distortions of self-perception and self-serving
bias. The majority of measures involved making judgements and evaluations on Likert scales.
In this study participants might have wanted to appear competent in their job and loyal to
their organisation, leading to greater agreement with statements about organisational support
and disagreement with organisational demands. It was assumed that completion of an online
survey and therefore assurance of participant anonymity would reduce this bias. Each
individual measure will now be discussed in terms of limitations.
Intellectual disability. Participants were asked to rate intellectual disability as mild,
moderate, severe or profound in line with categories defined in ICD-10 (World Health
Organisation, 2010). It’s likely that participant perception of the intellectual disability each
category defined differed from the actual criteria specified in ICD-10, and it’s possible that
participants made their choice based on their own perception of service users strengths and
needs. It could be suggested that people working in the field of intellectual disability would
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be able to make accurate distinctions between categories of mild and categories of severe or
profound disabilities. However it might be more difficult to distinguish between mild and
moderate, between moderate and severe, and between severe and profound intellectual
disabilities. Due to small numbers of participants in each category, two groups of mild-
moderate and severe-profound were created for further analysis. It’s possible that had
participants been given these two categories initially their selection might have been
different.
Checklist of challenging behaviour (Harris et al., 1994). A large number of
participants (66%) experienced behaviours on the Checklist of Challenging Behaviour but did
not rate their frequency or management difficulty high enough to label the behaviour as
‘challenging’. The remaining participants experienced between one and fifteen behaviours
frequently enough and found them more difficult to manage, thus perceiving them as
‘challenging’. The checklist itself could have been completed incorrectly, with participants
required to make two selections for each behaviour, for a total of 33 behaviours. The length
of the questionnaire might have put people off considering each behaviour individually. This
questionnaire might not have measured what it intended to i.e. number of challenging
behaviours participants were exposed to. Instead it could have measured self-efficacy as
discussed in section 4.3.1.2. The number of challenging behaviours was categorised into ‘yes’
and ‘no’ groups and had participants been given this explicit choice in the survey, as some
studies have through individual Likert scales, it’s possible participants might have answered
differently.
Staff stressor questionnaire (Hatton et al., 1998). The staff stressor questionnaire
had 9-items relating to client challenging behaviour and its effect on services and staff, and
poor client skill, similar to the variables of challenging behaviour and intellectual disability
measured separately. It’s possible that this one measure could have incorporated all three
97
stressors investigated in this study, with their combined effect found to be associated with
appraisals of emotional exhaustion.
Staff support and satisfaction questionnaire (Harris & Rose, 2002). In the present
study this questionnaire was used to measure organisational support, with lower levels of
support associated with higher levels of emotional exhaustion. The 5-item subscale of ‘job
satisfaction’ on this questionnaire might have crossed over with the separate study variable of
personal accomplishment. Though the relationship between personal accomplishment and
organisational support was not explored in this study, post hoc analysis did show that
personal accomplishment and emotional exhaustion were associated.
The social support questionnaire shortened version (Sarason et al., 1987). The use
of this questionnaire was limited in this study by the number of comparisons made. It was
decided that the social support number scale would be used alone as a measure of social
support, instead of using both ‘number’ and ‘satisfaction’ scales as the Shortened social
support questionnaire was intended. Due to the data collected on ‘satisfaction’ being skewed
it was decided that ‘number’ data would be used, with parametric tests identified as more
robust statistics (Field, 2013). This could have biased the criterion-related validity and
whether the questionnaire was measuring what it was intending to. For example participants
with low numbers of social support might have been very satisfied and conversely
participants with higher numbers of social support might have been very dissatisfied.
Shortened ways of coping revised (Hatton & Emerson, 1995). There did not appear
to be any limitations of using the shortened ways of coping revised scale in the present study.
Maslach Burnout Inventory-Human Services Survey (Maslach et al., 1996).
Participants were asked to complete the whole questionnaire but only the dimensions of
emotional exhaustion and personal accomplishment were used for data analysis. The
depersonalisation items could have been removed to decrease survey completion time but it
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was helpful to include the scale in order to compare the data in the present study with
normative data on staff burnout. The data collected from the depersonalisation scale was
positively skewed, therefore the mean was not an accurate portrayal of the spread of
participant scores. Using the dimensions of emotional exhaustion and personal
accomplishment as measures of secondary appraisals of job burden and job satisfaction
respectively was based on work stress and burnout theory and previous study findings
(Cordes & Dougherty, 1993; Maslach, 1982; Rose & Rose, 2005). It’s possible there are
other staff specific measures of job satisfaction that might have been considered, such as the
‘job satisfaction’ subscale of the 3SQ though this is only 5-items in length.
Positive affect and negative affect scale (Watson et al., 1988). A particular strength
of using this measure was that it included both positive and negative affect within one
measure. Other studies have used specific measures of negative emotions and distress such
as anxiety and depression (Chung & Harding, 2009; Mitchell & Hastings, 2001; Mutkins et
al., 2007) with Hastings and Horne (2004) developing a measure of positive perception to
support work but not explicitly testing positive feelings. It has been suggested that emotional
exhaustion measures the same construct as negative feelings (Rose & Rose, 2005) and it’s
possible that the PANAS was not measuring what it was intended to. Participants were asked
to rate their feelings over the last week. As psychological well-being is recognised as a
dynamic process that changes as personal and situational experiences change (Bradburn,
1969) it is not suggested that participants well-being is only associated with appraisals of
their job. Personality factors (Chung & Harding, 2009), physical health (Lawton et al., 1991)
and work, personal and family demands (Hatton et al., 1995) have all been identified to
influence well-being.
4.4.4. Sample. The study sample of 47 participants was less than planned and small in
comparison to previous research in this area. A priori calculations of sample size were
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undertake for seven comparisons using the Bonferonni approach and found that 77
participants were needed to achieve power of 80% for an effect size of .36. This number was
not reached however adjusted p-values for nine comparisons were calculated post hoc using
the Holm method to control for the experimentwise error rate and reduce the likelihood of
making a Type I error. Using this procedure five significant correlations were found in this
study with large effect sizes of between .50 and .69, significance to the level of p <.001, and
between 67% to 99% power. In this study four associations were not significant, with three
associations found to have effect sizes of .32 to .35 which might have been significant in a
larger sample. The small sample in this study increased the likelihood of accepting the null
hypothesis when it was false.
The use of voluntary survey methods may have biased the study sample, leading to
self-selected participants being unrepresentative of the population under investigation. There
may have been differences between people who chose to volunteer and participate and those
who did not. Rosenthal and Rosnow (2008) identified volunteers as being better educated,
higher in social class, more intelligent, more approval motivated and more sociable than non-
volunteers. It could be suggested that participants in this study showed greater motivation
around the work that they do through their act of participating. It is possible that people with
higher perceptions of organisational demands and higher appraisals of emotional exhaustion
would not want to undertake a job related research study in their spare time. This would
affect how the results of the present study can be generalised to the population of staff who
work with adults with intellectual disabilities.
In terms of sample demographics, the average participant was female (70%),
employed fulltime (66%) as a support worker or senior support worker (74%) in a residential
or supported living service (72%), educated to a level of NVQ3 or NVQ4 (73%) with an
average age of 39 years and average employment of 10 years in the intellectual disability
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field. This average participant is comparable with previous studies, specifically those with
much larger samples (Hensel et al., 2012; Hickey, 2014) suggesting that these results can be
generalised to the population of intellectual disability support workers with consideration of
sampling biases mentioned above. Further analysis of demographic variables with the main
study variables was not undertaken in this study to limit the number of comparisons made.
A detailed timeline of recruitment is provided in Appendix I. It is unknown how
organisations who agreed to participate may have advertised the study through their services.
Conversations between the researcher and organisations, resulted in participant recruitment
letters and advertising posters being handed over for distribution. Conversations over the
telephone and through email led to recruitment letters and advertising posters being post or
emailed to services. It is unknown whether all of the 459 recruitment letters sent out reached
staff or whether emails filtered through to support staff or attached letters were printed off
and handed to staff.
The length of the survey and time taken to complete it might have put people off from
participating in this study. The survey was initially advertised as taking between 45 and 60
minutes to complete. A read through and simulation of completing the online survey by three
people took on average 30 minutes. This time was then increased to incorporate slower
reading speeds and limited computer skills in order to gauge the maximum time is might take
someone to complete the survey. A more comprehensive pilot study could have been
conducted, asking people who met the sample criteria to complete the online survey, to
provide a more accurate completion time. After 15 people had completed the survey the
approximate time for completion was calculated as 25 minutes with the majority of people
taking between 20 and 40 minutes (some people clocked hours and days due to the fact the
survey could be saved and returned to). The advertising poster and recruitment letter were
subsequently amended to reflect the average completion time.
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Initial recruitment strategies targeted organisations in order to recruit a homogenous
group of participants meeting the criteria of support or senior support workers in residential
or supported living services for adults with intellectual disabilities. Using a varied sample of
roles was one of the criticisms of previous research found during the systematic literature
review. A varied sample would impact on what conclusions could be drawn from the study as
different roles could have very different job stressors. Managers have less direct contact with
service users, are involved in the recruitment, rotating, supervision, and disciplining of staff,
and would have pressures concerning service delivery and meeting organisational targets.
Trainers deliver mandatory and person-specific teaching to the staff team as part of their role.
Both of these roles could involve direct interaction with service users and on occasion one to
one support. It would be expected that people employed in managerial or training positions
have greater experience in intellectual disability services and greater education or training in
the area than support workers. This could have led managers and trainers to develop ways of
coping with job stressors in order to progress, to be more invested in their organisation and be
less likely to report symptoms associated with burnout.
Due to recruitment difficulties the selection criteria for participation was widened to
support staff, including managerial and training roles, working in community services,
including day, activity and study. The study was subsequently advertised on the internet to
recruit more participants, with the recognition that the sample may be biased due to
individual perception of meeting the selection criteria. Questions about the service employed
in and how the participant heard about the study were added to the survey before
advertisements were placed on the internet, to act as a control method.
Using this information participants could be removed from analysis if they worked in
secure/inpatient settings and if they reported a job role that obviously did not meet the criteria
e.g. probation officer. Participants could also be removed if they did not undertake any direct
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support tasks with adults with intellectual disabilities (scored 0 on the ‘Support given to
adults with learning disabilities’ questionnaire). Only three people who participated in this
study were removed due to not meeting criteria. Despite not being included in the analyses of
the results these participants were still eligible to take part in the prize draw if they had
signed up to this. Further checks of the data found that there were no associations between
intellectual disability service employed in or method of hearing about the study and any of
the main study variables.
Through a visual check of the data the internet survey appeared to have been
completed appropriately by the majority of participants. There were five participants who did
not complete the satisfaction of social support correctly, though completion of this
questionnaire was made more difficult by the specific template provided by the internet
survey provider. Through the manual search procedure there appeared to be no anomalous
data provided or patterns of completion that suggested participants were not responding
accurately (e.g. answering all questions with the same response).
4.4.5. Statistical analysis. The cross-sectional nature of the survey means causal
mechanisms of the underlying processes of the staff well-being model could not be identified.
The idea of conceptualising the staff well-being model was to test it through structural
equation modelling for goodness of fit of the data; this was not possible in this study due to
the number of participants required. Structural equation modelling has been used to test
different models proposed in intellectual disability staff stress and burnout research (Rose &
Rose, 2005) and is used to find out whether variables reliably predict other constructs with
which they are theoretically linked (Judd, Jessor & Donovan, 1986). Structural equation
modelling allows exploration of the variances and covariance’s of the variables in a
hypothesised model to establish goodness of fit (Rose & Rose, 2005) and will estimate
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relationships between variables without the biasing effects of measurement error (Judd et al.,
1986).
The number of participants also limited the number of comparisons that could be
made between variables in the hypothesised staff well-being model, with other interesting
relationships not explored (as detailed above). Multiple staff variables have been tested in
previous research through studies with larger samples (Gray-Stanley & Maramatsu, 2011;
Hensel, Lunsky & Dewa, 2012; Hickey, 2014) or those that have appeared to undertake
multiple comparisons with small sample sizes (Mascha, 2007).
Confounding variables of partial correlations were not explored or controlled for in
this study to limit the number of comparisons made (Meltzoff, 1998). Associations between
demographic variables that have been reported in previous research, between
depersonalisation and marital status (Mascha, 1997), and sex (Mutkins et al., 2011), were not
explored. Maslach (1981) reported overall burnout experience is similar between women and
men, with women showing slightly more emotional exhaustion and men showing slightly
more depersonalisation. It is possible that covariate variables could have affected the results
of this study. Potential confounding variables of the study procedure and experimenter bias
were minimal through the use of a structured online survey that provided information and
collected data in exactly the same way for each participant.
Non-parametric statistical tests of correlation were used for variables of emotional
exhaustion, wishful thinking and negative feelings due to data on these scales violating the
assumption of normality. Spearman’s rank correlation coefficient ranks the data to reduce the
impact of outliers and skewed distributions, but in doing so is less powerful than the
parametric equivalent of Pearson’s product-motion correlation coefficient (Field, 2013). It is
possible that using non-parametric tests reduced the power of results found in this study.
104
4.5. Implications of the Research Findings
4.5.1. Theoretical implications. The theoretical implications of the study findings are
limited due to the aim of this study being a preliminary exploration of relationships between
variables in the staff well-being model and the methodological limitations highlighted. The
theoretical model was conceptualised from Lawton et al.’s (1991) two-factor model of
caregiving appraisal and psychological well-being. Lawton et al.’s two-factor model was
itself conceptualised from cognitive-behavioural theory and Lazarus and Folkman’s (1984)
transactional model of stress, appraisal, and coping, and from Bradburn’s (1969) two-factor
theory of happiness.
In line with cognitive-behavioural theory of work stress and Lazarus and Folkman’s
transactional model of stress, the stressor of organisational demands was found to be
associated with the secondary appraisal of job burden. Also in support of this theory,
participants who had low levels of organisational resources and participants who used greater
levels of emotion-focused coping, reported greater levels of secondary appraisals of job
burden. In line with Lawton et al.’s (1991) two factor model of caregiving appraisal and
Bradburn’s (1969) theory of independent dimensions of well-being, associations were found
between appraisal of job satisfaction and positive affect, and between appraisal of job burden
and negative affect. Exploratory secondary analyses suggested that these two processes may
have been separate and distinct, however these were not part of the main study findings and
the relationships would need to undergo further hypothesis testing. Structural equation
modelling would need to be used to test whether the theoretically associated variables in the
staff well-being model reliably predict one another and can further our understanding of staff
stress through a cognitive-behavioural framework.
4.5.2. Clinical implications. The aim of this study was to undertake a preliminary
investigation of relationships between variables in the staff well-being model and therefore
105
the clinical implications are limited by the design. This study found 27.8% of participants
reported high levels of burnout as measured by the emotional exhaustion scale of the MBI-
HSS. The average score on the emotional exhaustion scale in this study was comparable with
the findings of Skirrow and Harrow (2007) and lower than the normative data for the MBI-
HSS (Maslach et al., 1996). However, it is still of interest to highlight that a quarter of the
sample reported symptoms associated with job burnout.
The effect of emotional exhaustion on staff interactions with service users and
interrelations with the staff team was not investigated in this study. It is relevant though for
clinical psychologists to find out whether support staff are experiencing symptoms of burnout
in order to develop and implement interventions with them to reduce distress. As Devereux,
Hastings, Noone, Firth et al., (2009) found in their longitudinal study that negative
dimensions of burnout appeared to be long lasting.
The results of this preliminary study were in line with cognitive behavioural models
of work stress, with organisational demands, low organisational resources and emotion-
focused coping strategies associated with appraisals of job burden. The clinical implication of
the findings would therefore suggest interventions based on a cognitive behavioural model
aimed at reducing emotion-focused coping. Intervention studies in the research literature have
identified mindfulness-based interventions based on Acceptance and Commitment Therapy to
be appropriate for reducing psychological distress in intellectual disability staff. The results
of these studies are mixed and limited due to small samples sizes. Intervention studies have
identified that mindfulness-based workshops are helpful for participants, particularly those
who report the most initial distress (Bethay et al., 2013; Ingham et al., 2013; McConachie,
McKenzie, Morris, & Walley, 2014; Noone & Hastings, 2009). Other interventions have
explored goal focussed stress-management interventions that explore stress models, stress
management and problem solving techniques (Hodgkins et al., 2005).
106
4.5.3. Research implications. The aim of this research was to investigate
relationships between variables associated with staff well-being. Preliminary reading
identified numerous staff variables that had been investigated over the last 30 years with no
consensus about a theoretical model through which to link the relationships found.
Discovering the Lawton et al. (1991) study was exciting as a theoretically based model
through which many variables could be tested at once, with the possibility that several
relationships could be identified. Encouragement for exploring the model was increased by
finding it had been tested in many different caregiving populations but not intellectual
disability staff, and it had recently been suggested by leading academics in the field as a
model to test.
A year into the research project and it was realised that the study would not recruit
enough participants in order to undertake structural equation modelling. The design remained
the same, undertaking correlational analyses of staff variables; however the initial proposal of
testing a new model was gone. The number of hypothesised relationships tested were reduced
and those that were undertaken had reduced power due to the sample number.
A lot has been learned about undertaking research through this study. In hindsight the
enthusiasm for trying to incorporate all the variables into one model to test was greater than
that allowed for a time-limited thesis research study. In particular a study making use of
untested online survey methods with a potentially unmotivated population. The take home
message from this experience has been to recognise the worth of a project that might not be
making massive leaps forward in the research field but is theoretically justified and
methodologically robust.
4.6. Future Research
Based on the findings of the present study the staff well-being model warrants further
exploration. Investigating the model with a larger sample would increase the power of the
107
findings and would allow the predictive validity of the theoretical model to be tested through
structural equation modelling.
Relationships that were hypothesised based on the theoretical predictions of Lazarus
and Folkman’s (1984) transactional stress model but were not significant in this study could
be investigated further (e.g. practical coping and personal accomplishment). Relationships
that were tentatively explored in this study through post hoc analysis between appraisals and
outcomes could be investigated further to test whether there are two parallel processes
between appraisals and their predicted outcome, as suggested by Bradburn (1969) and found
by Lawton et al., (1991).
Relationships that were not explored in this study could be investigated based on the
findings of previous studies, for example challenging behaviour and personal
accomplishment (Hensel et al., 2012), organisational support and personal accomplishment
(Mascha, 2007), and social support and emotional exhaustion (Aitken & Schloss, 1994).
Longitudinal studies could also be undertaken to investigate causal relationships between
variables in the staff well-being model.
4.7. Conclusions
In conclusion, a theoretical staff well-being model was developed and tested with
support staff of adults with intellectual disabilities and challenging behaviour in community
services. The model was based on the structure of Lawton et al.’s (1991) two factor model of
caregiving appraisal and psychological well-being, which was conceptualised from Lazarus
and Folkman’s (1984) theoretical model of transactional stress and Bradburn’s (1969) two-
factor theory of happiness. Using the results of a systematic literature review of intellectual
disability staff burnout, staff variables associated with stress, burnout and well-being were
identified as stressors, resources, appraisals and outcomes.
108
Nine hypothesised relationships between staff variables were explored through an
online survey and five significant relationships were found. In answer to the first research
question an association was found between the stressor of organisational demands and the
appraisal of emotional exhaustion. In relation to the second research question associations
were found between the resource of organisational support and appraisal of emotional
exhaustion, and between the resource of wishful thinking and the appraisal of emotional
exhaustion. In terms of the third research question, there was an association between the
appraisal of personal accomplishment and outcome of positive affect, and an association
between the appraisal of emotional exhaustion and outcome of negative affect.
These study findings were discussed in light of methodological limitations of the
small sample size, multiple comparisons and correlational design. Theoretical and clinical
implications were limited due to this study undertaking a preliminary exploration of a new
model. Further exploration of the staff well-being model is warranted due to its theoretical
conceptualisation and investigation with a larger sample size would allow the model’s
predictive validity to be tested.
109
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Appendices
Appendix A: Systematic literature review method
Appendix B: Organisation study information including advertising poster and
recruitment letter
Appendix C: Advertisement for online forums
Appendix D: Online survey including questionnaire measures
Appendix E: Permission to use Maslach Burnout Inventory
Appendix F: University of East Anglia Faculty of Medicine and Health Sciences
Ethics Committee Approval Letters
Appendix G: Box plots and histograms of the main study variables
Appendix H: Box plot, scatter graphs and SPSS output for the main results
Appendix I: Timeline of recruitment
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Appendix A.
Method for conducting a systematic literature review for research into burnout and
staff
Inclusion Criteria
This review specifically identified studies sampling direct care workers in community
services for adults with intellectual disabilities. Studies were excluded if they sampled staff
working in inpatient units, or with clients who had a specific mental health diagnosis, or with
explicitly mixed client populations e.g. older adults, physically disabled, children. Studies
were included if they measured burnout using the MBI-HSS (Maslach et al., 1996). Studies
were included if they were from an English language journal and had been subjected to peer-
review.
Search Procedure
A systematic search of the EMBASE, MEDLINE, PsychINFO, BNI and CINAHL
online databases was performed for dates between 2004 and the 3rd
April 2014, using the
following Boolean variable string: burnout AND (disab* OR retard* OR handicap*). This
discovered 357 results, of which 195 were found to be duplicates. This identified 138 unique
references for further consideration. From these remaining articles, 84 did not relate to carers
with adults with intellectual disabilities, investigating other occupations or the general
population (22), physical or mental health conditions (19), educational staff (15), family
carers or carers of other populations (14), medical staff (9), students (4), and prison staff (1)
Of the remaining 54 references, 15 were excluded for not reporting direct research:
four were presentations from the 2012 IASSID World Congress, six of these were narrative
reviews, two were developing psychometric measures, two were conducting factor analysis
of a measure, and one was a dissertation abstract. Nine studies were excluded for using other
132
burnout inventories or not using the standard MBI-HSS. A further 13 studies were excluded
for not meeting the sample population criteria: six studies sampled a mixed population of
staff with ID and other physically or mental health disabled populations, four sampled staff
working in inpatient units, two sampled staff working with people with ID and other specific
disorders e.g. dementia, and one sampled staff from a summer camp.
This systematic process revealed 16 studies that met the criteria of sampling staff
working with adults with intellectual disabilities in community services, and measuring
burnout with the MBI-HSS. Further searches using the ancestory method and the internet
search engine Google Scholar revealed no other studies that met the review criteria. A flow
diagram of the search procedure and table of the results of the literature search are shown
below.
133
Flow Diagram of Search Procedure
Further consideration
n = 138
Excluded (n = 195)
Duplicates
Excluded (n = 84)
General population/other employment
studies (22)
Physical disability/injury or mental
health conditions (19)
Educational staff/teachers (15)
Other carers e.g. family, older people
(14)
Medical staff (9)
University/college students (4)
Prison staff (1)
Further consideration
n = 54
Excluded (n = 38)
Not research articles (15)
Didn’t use MBI measure (10)
Mixed intellectual disabilities and other
physically disabled clients (6)
Inpatient units (4)
Clients with Intellectual Disabilities and
specific disorders (2)
Summer Camp (1)
Studies found through the systematic search
n = 16
Search of OVID and EBSCOHost
databases
EMBASE
MEDLINE
PsychINFO
BNI
CINAHL
Limit 2004 to current date
n = 357
Further search (n = 0)
Google Scholar
Ancestory
Method of
journal articles
Key journals e.g.
JARID, JIDR
134
Nicola Brame 3
rd Year Trainee Clinical Psychologist
Doctoral Programme in Clinical Psychology Norwich Medical School University of East Anglia
Norwich, NR4 7TJ
Telephone: 07581 065743 Email: [email protected]
Dear Colleague, Research investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour My name is Nicola Brame and I am a trainee clinical psychologist studying on the Doctoral Programme in Clinical Psychology at the University of East Anglia. My thesis research study is investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour. The study is recruiting support workers to complete an anonymous online survey in their own time and has been approved by the University of East Anglia Faculty of Medicine and Health Sciences Research Ethics Committee. I am currently identifying suitable organisations and asking for permission to advertise the study within their community services for adults with learning disabilities through posters placed in staff areas and recruitment letters distributed to staff. I would like to invite your organisation to take part and have provided further information about what this would involve and why this research is important on the accompanying document. I have also provided examples of what the recruitment letter and advertising poster look like. If you would like further information or are interested in taking part please contact me at [email protected] or telephone 07581 065743. Thank you for your time, Yours sincerely, Nicola Brame Trainee Clinical Psychologist Research supervised by Professor David Peck
Thesis Research Study for the University of East Anglia
Doctoral Course in Clinical Psychology
Appendix B
Organisation study information.
135
Research investigating the wellbeing of staff working with adults with learning disabilities in community services
Why is this research important?
Previous research has identified that whilst staff in intellectual disability services may not be at increased risk of burnout compared to staff in other human services, staff experiencing high levels of burnout are more likely to be absent or leave their employment. This may lead to a disruption of care to service users, financial costs to their organisations, and the loss of specific staff skills.
It is hoped that this study will lead to a better understanding of job burnout, job satisfaction and psychological wellbeing of staff in learning disability services. This can then be used to support staff and improve their ability to provide support to adults with learning disabilities.
What does the research involve?
Organisation
The organisation will be asked to provide written confirmation stating that they are willing to advertise the study to their staff.
The organisation will be provided with a) study recruitment letters and asked to distribute these amongst their staff and/or b) study recruitment posters and asked to place these on staff notice boards.
The survey is anonymous and no identifying information about the organisation or service users is requested.
All organisations that provide permission for the study to be advertised to their employees will be provided with a summary of the research findings.
Participants
Will be requested to visit a website in their own time and complete an anonymous online survey that takes between 20 and 40 minutes to complete.
Will be required to read through the participant information sheet and provide their informed consent to take part.
Participants will be asked questions about the following subjects: 1. Demographic information 2. The challenging behaviours of service users they work with 3. The support they give to service users 4. Sources of work stress 5. The way they cope with stressful work situations 6. Work support and satisfaction 7. The social support they get from friends and family 8. Job burnout 9. Their current positive and negative feelings
All participant information provided will be stored securely and confidentially.
As a thank you for taking part in the study participants will have the opportunity to enter a ‘prize draw’ to win one of two £50 Love2shop gift vouchers.
Participants will be able to access a summary of the research findings through a webpage provided to them at the end of the survey.
Thesis Research Study for the University of East Anglia
Doctoral Course in Clinical Psychology
136
Research study recruiting support staff who
work with adults with learning disabilities and
challenging behaviour in community services
This psychology study is investigating how staff cope with the demands of support
work, and how this impacts on their job satisfaction and wellbeing
This study is:
Internet based
Anonymous - you do not need to provide your name, your place of work or
details of the people you work with
Confidential - all data provided will be stored confidentially and securely in
accordance with data protection policies
Not going to feedback your individual answers to your employers - a summary
of the results will be available to all participants when the study is completed
To take part:
Go to the webpage address http://tinyurl.com/NBstaffsurvey
Read the participant information sheet
Give consent to take part in the study
Complete the 20-40 minute survey
Any questions? Contact the researcher Nicola Brame, Trainee Clinical Psychologist, on 07581 065743
or email [email protected], or research supervisor Prof David Peck at [email protected]
This study has been given ethical approval by the University of East Anglia Faculty of Medicine and
Health Sciences Research Ethics Committee.
Participants can enter a prize draw to win one of
two £50 Love2shop vouchers
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Thesis Research Study for the University of East Anglia
Doctoral Course in Clinical Psychology
137
Research investigating the wellbeing of staff working with adults with learning disabilities in community services
Dear Colleague, I would like to invite you to take part in my research study. The purpose of this study is to investigate how the work that you do impacts on your personal wellbeing. To find out how satisfied you are with the work that you do, and how this might impact on how positive and negative you feel at the moment.
I’m looking to recruit 33 more people before 30th April 2014 (to reach a total of 77) and all participants
can enter a prize draw to win one of two £50 Love2shop vouchers.
The study involves the completion of an online survey asking you about challenging behaviours you work with, support you give, sources of work stress, ways you cope with stressful work situations, work support and satisfaction, social support, job burnout, and current positive and negative feelings.
This study is Anonymous. You do not need to provide your name, your place of work, or any identifiable details of the people you work with.
The study is Confidential. All the information you provide will be stored confidentially and securely in accordance with data protection policies.
This study is not going to feedback your individual answers to your employers. A summary of the results will be available to all participants and all organisations who agreed for the research to be advertised within their services.
If you want to take part:
Go to the webpage address http://tinyurl.com/NBstaffsurvey
Read through the participant information sheet
Give your consent to take part in the research study
Give your answers to the questionnaires. You can save your answers at any point and continue at a later time. The survey will take approximately 20 to 40 minutes.
Complete the prize draw information sheet if you want the chance to win one of two £50 Love2shop vouchers.
This study has been given ethical approval by the University of East Anglia Faculty of Medicine and Health Sciences Research Ethics Committee. If you have any questions please email me at [email protected] or telephone 07581 065743. Kind Regards,
Nicola Brame Trainee Clinical Psychologist
Address: Doctoral Programme in Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ Tel: 07581 065743 Email: [email protected]
Thesis Research Study for the University of East Anglia
Doctoral Course in Clinical Psychology
Thesis Research Study for the University of East Anglia
Doctoral Course in Clinical Psychology
138
Appendix C
Advertisement for online forums
My name is Nicola Brame and I'm conducting a thesis research study investigating the wellbeing of
support staff working with adults with learning disabilities and challenging behaviours. I'm recruiting
support workers from non-NHS community services (e.g. residential, supported living, day, study,
and activity) to complete an anonymous and confidential online survey. The survey is asking about
challenging behaviours, job demands, ways of coping, support, job satisfaction, job burnout, and
wellbeing, and is taking an average of 30 minutes to complete. The study has been granted ethical
approval from the University of East Anglia and all participants can enter a prize draw to win one of
two £50 Love2shop vouchers. If you would like to find out more about the study please follow the
link http://tinyurl.com/NBstaffsurvey If you decide to take part you will be asked to read through the
participant information sheet and give your consent before accessing the survey. If you have any
questions about this study please contact me at [email protected]
139
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
0%
Thank you for your interest in this research study. This psychology study is investigating how staff cope with the demands of support work, and how this impacts on their job satisfaction and wellbeing.
This study is recruiting participants meeting the following criteria: 1. Working with adults with learning disabilities 2. Working in non-NHS community services: residential, supported living, activity, study, or day services 3. Working in a support worker/direct care role or a similar position with supportive duties
This study is Anonymous You do not need to provide your name, your place of work, or any identifiable details of the people you work with.
This study is Confidential All the information you provide will be stored confidentially and securely in accordance with data protection policies.
This study is not going to feedback your individual answers to your employers A summary of the results will be available to all participants and all organisations who agreed for the research to be advertised within their services.
If you want to take part you will be asked to: 1. Read through the participant information sheet. 2. Give your consent to take part in the research study. 3. Give your answers to the questionnaires. This is taking an average of 30 minutes and you can save your answers at any point and continue at a later time. 4. Tick a box to say that you agree to submit your answers to the questionnaires. 5. Complete the prize draw information sheet if you want the chance to win one of two £50 Love2shop vouchers.
Appendix D
Online survey including questionnaire measures
140
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
6%
Participant Information Sheet (Feb 2014 version 1.2) This question requires an answer.
We would like to invite you to take part in our research study.
Before you decide we would like you to understand why the research is being done and
what it would involve for you.
Please read through the participant information sheet or listen to a recorded spoken
version provided below. Please take your time to consider the information and
whether you would like to take part in this study. Please contact the researcher Nicola
Brame on 07581 065743 if you have any questions about the study.
Once you have read through or listened to the participant information sheet please
select the appropriate tick box option below to show whether you would or would not
like to provide consent to take part in the study:
*
I have read or listened to the participant information sheet and would like to proceed to
the Consent Form
I do not want to take part in this research study
A word copy of the participant information sheet can be opened, read and saved by selecting this link /_files/cabinet/34953/InformationDoc.docx A recorded spoken version of the participant information sheet can be listened to by selecting this link /_files/cabinet/34953/Information.MP3
Participant Information Sheet (Feb 2014 Version 1.2) What is the purpose of the study? The purpose of this study is to investigate how the work that you do impacts on your personal wellbeing. To find out how satisfied you are with the work that you do, and how this impacts on how positive and negative you feel at the moment. This study is primarily educational and is a thesis research project to fulfil the academic requirements for the University of East Anglia Doctoral Programme in Clinical Psychology.
141
Why have I been invited? You have been invited to take part because you work as a support worker in a non-NHS community service for adults with learning disabilities and challenging behaviours. There will be a total of 77 participants who meet these same criteria who will take part in this study. Do I have to take part? To participate in this study is voluntary, and it is up to you to decide to join the study. If you read through this information sheet and agree to take part, we will ask you to complete a consent form. You are free to withdraw at any time, without giving a reason. What will happen to me if I take part? You will be asked to complete an online survey. You will not need to provide your name or any information that would lead to someone recognising who you are from your answers. You will not need to provide any information about where you work or the service users you work with. How long it will take to complete the online questionnaire will vary but it should take between 20 and 40 minutes. After completing the online questionnaire you will have the opportunity to enter a ‘prize draw’ to win one of two Love2shop gift vouchers worth £50 each (redeemable at High Street Shops, restaurants and leisure attractions). This is to say thank you for taking part in this study. If you want to enter the prize draw you will need to provide your name and an email address in order for us to contact you if you win. If you do provide these personal details they will be stored securely and separately from your answers to the questionnaires, to make sure your answers are provided anonymously. The prize draw will be made at the end of the study, after which all the contact details of participants who enter will be destroyed. What will I have to do? You will need to visit a web page through a computer with internet access. You will be asked to read this information again and tick a box to say that you have. You will be asked to read a consent form and tick a box to say you have read this and you consent to take part in this research study. You will then be asked to answer questions about the following subjects: 1. Your age, gender, marital status, education, and current employment. You will be given a ‘Prefer not to answer’ option for these questions except you will have to provide information about your job title e.g. support worker, senior support worker, night support worker. 2. The challenging behaviours of service users you work with 3. The support you give to service users 4. Sources of work stress
142
5. The way you cope with stressful work situations 6. Work support and satisfaction 7. The social support you get from friends and family 8. Job burnout 9. Your current positive and negative feelings
Will my taking part in this study be kept confidential? Once you have completed the questionnaires your answers will be stored securely and confidentially within the online survey database and then an encrypted memory device which only the researcher will be able to access through a password-protected service. After the completion of the study, your data will be stored confidentially and securely for 5 years at an archiving company used by the University of East Anglia Medical School, after which it will be destroyed. Your employers will not know whether you are taking part in this study as your answers will be provided anonymously. There is no possible way for your answers to be fed back to your employers. A summary of the results of this study will be made available to all participants to view through a web page address provided after completing the survey. The summary of results will be posted to the organisations that have provided permission for the researcher to contact their staff. No individual participant or their answers will be identifiable within these results. How will I be able to withdraw from the study? If you look at the survey online and decide you do not want to complete it, you will be free to withdraw from the study by not submitting your answers to the questionnaires. However due to this study being anonymous if you complete the survey online and submit your answers it will not be possible to withdraw from the study at a later date. Who has reviewed the study? All research is looked at by an independent group of people, called a Research Ethics Committee, to protect your interests. This study has been reviewed and given a favourable opinion by the University of East Anglia Faculty of Medicine and Health Sciences Research Ethics Committee. Further information and contact details If you would like further information about this research or if you have concerns about any aspect of this study, please contact the primary researcher Nicola Brame on 07581 065743 or at the email address [email protected]. If you have any further questions you can contact the research supervisor Prof David Peck at the email address [email protected].
143
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
12%
Consent Form
Title of the Project: Investigating the wellbeing of staff working with adults with learning
disabilities and challenging behaviour.
Name of Researcher: Nicola Brame
I confirm that I have read and understood the information sheet dated Feb 2014
(version 1.2) for the above study. I have had the opportunity to consider the
information, ask questions and have had these answered satisfactorily.
I understand that my participation is voluntary and that I am free to withdraw from the
study by not submitting my answers to the online questionnaire.
I agree to take part in the above study.
This question requires an answer.
Please select the appropriate option: *
I have ticked all three boxes of the Consent Form and I wish to proceed to the
questionnaires
I have not ticked all three boxes therefore I will be unable to participate in this study
144
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
19%
Demographic Information
Please provide information about your age, gender, marital status, and education. Please select from the options the answers that most accurately describe you. You do not need to provide this information if you don't want to. In this case leave the answer blank or select 'prefer not to answer' and move on to the next question.
1. Age
DD/MM/YYYY
Date of Birth
2. Gender
Male
Female
Prefer not to answer
3. Marital Status
Single
Cohabiting/Married/Civil Partnership
Separated/Divorced/Widowed
Prefer not to answer
4. Education and Qualifications
NVQ Level 1 or equivalent e.g. < 5 GCSE's
NVQ Level 2 or equivalent e.g. 5 GCSE's, O-Levels
NVQ Level 3 or equivalent e.g. A-Levels
NVQ Level 4 or equivalent e.g. Degree, BSc, BA
NVQ Level 5 or equivalent e.g. Higher Degree, MSc, PhD
Prefer not to answer
145
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
25%
Employment
Please select from the following options the answers that most accurately describe your current employment and work experience. You are required to provide information about your current job role. You do not need to answer the other questions if you don't want to. In this case leave the answers blank or select 'prefer not to answer' and move on to the next question.
This question requires an answer.
5. What is your current job title? You are required to give an answer to this question.
*
Support Worker
Night Support Worker
Senior Support Worker
Other (please specify):
6. What are your current working hours?
Full Time
Part Time
Bank Worker
Prefer not to answer
7. How much experience do you have working with adults with learning disabilities?
Years Months
Time spent in current job
Total time spent working with people with learning disabilities
and challenging behaviour
146
8. What training have you had on challenging behaviour?
No formal training on challenging behaviour
Limited training e.g. one or two courses
Detailed training e.g. three or more courses
Prefer not to answer
9. How would you categorise the learning disabilities of the adults you work with in
your current employment? If you work with multiple categories of learning disability please select the most severe.
Mild
Moderate
Severe
Profound
10. How would you describe the services you work in?
Residential or supported living service
Inpatient service
Day or Activity service
Other (please specify):
11. How did you find out about this research study?
Through my work organisation e.g. recruitment letter, advertising poster, work
colleague
Through a friend or family member
Through an advertisement on the internet
147
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
31%
The Checklist of Challenging Behaviour (Harris, Humphreys, & Thomson, 1994) This question requires an answer.
Has any service user you work with exhibited any of the following behaviours during
the past three months?
Please think about all the adults with learning disabilities you work with and select a
number between 1 - 5 from the drop down menu to reflect the frequency and
management difficulty for each behaviour.
Frequency: How often has this behaviour occurred during the past three months?
1 = Never: This behaviour has not occurred during the past three months
2 = Rarely: Has occurred during the past 3 months but not in the past month
3 = Occasionally: 1 – 4 times in past month
4 = Often: More than 4 times in past month
5 = Very often: Daily or more often
Management Difficulty: How difficult do you find it to manage this situation?
1 = No problem: I can usually manage this situation without any difficulty at all
2 = Slight problem: I can manage this situation quite easily although it does cause me some
difficulty
3 = Moderate problem: I find this situation quite difficult to manage, but I feel confident
that I can
4 = Considerable problem: I find it very difficult to manage this situation on my own
5 = Extreme problem: I simply cannot manage this situation without help
Please rate the following behaviours in terms of frequency and management difficulty.
*
Frequency
Management
Difficulty
Pinching people
Biting people
Scratching people
Hitting out at people (i.e. punching or slapping)
Grabbing, squeezing, pushing or pulling people
Kicking people
Headbutting people
148
Pulling people's hair
Choking or throttling people
Using objects as weapons against people (e.g. knife or
other hand held object)
Throwing things at people
Tearing other people's clothes
Making unwanted sexual contact
Injuring self (e.g. head banging, eye poking/gouging,
biting or scratching self)
Damaging clothes, furniture or other objects
Smashing windows
Slamming doors
Shouting and swearing at people
Making loud noises (e.g. banging, screeching,
screaming)
Threatening to hurt others (either verbally or non-
verbally)
Taking food or drink from others
Eating inappropriate things (e.g. rubbish, faeces,
dangerous objects)
Displaying ritualistic or repetitive behaviour ( e.g.
closing/opening doors, rearranging furniture, hoarding
rubbish etc)
Engaging in stereotyped behaviour (e.g. bodyrocking,
finger tapping, hand waving etc)
Showing withdrawn behaviour (i.e. difficult to reach
or contact)
Spitting at people
Deliberately soiling, wetting or vomiting
Smearing or flicking faeces (or anal probing)
Exposing his or her body inappropriately (e.g.
stripping or masturbating in public)
Refusing to do things (e.g. to eat or to move)
Absconding or trying to abscond from facility
149
Causing night time disturbance
Harris, P., Humphreys, J., & Thomson, G. (1994). A Checklist of Challenging Behaviour: The development of a survey instrument. Mental Handicap Research, 7, 118-133.
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
38%
Support given to adults with learning disabilities (Lawton et al., 1991) This question requires an answer.
How frequently during your last five working days did you support a service user with
the following tasks? *
No days One day
Two of
three days
Four or
five days
Feeding
Dressing
Grooming e.g. making hair, face or skin look
nice
Toileting
Bathing
Giving Medicine
Banking and financial management
Moving from place to place, e.g. support to
walk or move, using manual handling
techniques
Transportation e.g. driving a car, using public
transport
To go into the community e.g. shops, leisure
activities, college
Lawton, M. P., Moss, M., Kleban, M. H., Glicksman, A., & Rovine, M. (1991). A Two-Factor Model of caregiving appraisal and psychological well-being. Journal of Gerontology: sychological Sciences, 46, P181-189.
150
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
44%
Staff Stressor Questionnaire (Hatton et al., 1999) This question requires an answer.
Please rate how stressful you find the following possible sources of stress on the five
point scale from '1 = Not at all' to '5 = A great deal'.
How stressful do you find:
*
Not at
all
1
Just a
little
2
Moderate
amount
3
Quite a
lot
4
A great
deal
5
The physical work conditions
The work load
Lack of sufficient staff and resources
Low levels of user mobility
Doing domestic tasks
Low levels of user self-care skills
Uncertainty about what the job involves
Doing paperwork/administration
Lack of/slow service user progress
Lack of support from outside work
User behaviour causing injury to others
Lack of support from management
Low levels of user communication skills
Physical strength of users
The hours of the job
Low levels of user domestic skills
151
Lack of job security
User self-injury
Lack of procedure for effectively dealing
with user challenging behaviour
Low income
The organisation's rules and regulations
User destruction of property
The emotional impact of the job
User stereotyped behaviours
Lack of training opportunities
Unpredictable user challenging behaviour
Lack of support from colleagues
Inappropriate sexual behaviour
Too much routine
Lack of promotion prospects
Personal care of service users
Lack of support from immediate superior
Conflicts between work and home
Hatton, C., Emerson, E., Rivers, M., Mason, H., Mason, L., Swarbrick, R., Kiernan, C., Reeves, D., & Alborz, A. (1999). Factors associated with staff stress and work satisfaction in services for people with intellectual disability. Journal of Intellectual Disability Research, 43, 253-267.
152
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
50%
The shortened ways of coping questionnaire (Hatton & Emerson, 1995) This question requires an answer.
Please focus on how you cope with problems at work and rate each item on the scale
from '1 = Not used' to '4 = Used a great deal'.
How do you cope with the following problems at work?
*
Not used
1
Used
Somewhat
2
Used
Quite
a bit
3
Used a
Great deal
4
I daydream or imagine a better time or place
than the one I am in
I draw on my past experiences
I think up a couple of different solutions to
problems
I wish that I could change how I feel
I try to come out of experiences better than
when I went in
I wish that I could change what has happened
I try to analyse the situation in order to
understand it better
I usually know what has to be done, so I keep
up my efforts to make things work
I take it out on other people
I avoid being with people in general
I have fantasies or wishes about how things
might turn out
I stand my ground and fight for what I want
I wish that the situation would go away or
somehow be over with
I make a plan of action and follow it
153
Hatton, C., & Emerson, E., (1995). The development of a shortened 'ways of coping' questionnaire for use with direct care staff in learning disability services. Mental Handicap Research, 8, 237-251.
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
56%
The staff support and satisfaction questionnaire (Harris & Rose, 2002)
The following questions are asking about yourself and your place of work. For each question please rate yourself on the scale from 5 to 1.
This question requires an answer.
1. *
Very
Clear
5
4
3
2
Very
Unclear
1
How clear are you about the main objectives
you should be working towards in your job
How clear are you about what your direct
line manager expects from you?
How clear are you about the limits of your
responsibility in your present position?
How clear are you about how satisfied your
direct line manager is with what you do?
This question requires an answer.
2a. *
Always
5
4
3
2
Never
1
Is there somebody you can talk to at work if
you are experiencing difficulty in your job?
This question requires an answer.
2b.Considering your answer to the last question. *
154
Very
Satisfied
5
4
3
2
Very
Dissatisfied
1
How satisfied are you with this?
This question requires an answer.
3a. *
Always
5
4
3
2
Never
1
If you were unable to cope with a situation
at work, is there anybody you can call on for
practical help?
This question requires an answer.
3b. Considering your answer to the last question *
Very
Satisfied
5
4
3
2
Very
Dissatisfied
1
How satisfied are you with this?
This question requires an answer.
4a. *
Very
Clear
5
4
3
2
Very
Unclear
1
How clearly have personal risk situations
been identified at your place of work? (i.e.
situations that may threaten you personally)
This question requires an answer.
4b. Considering your answer to the last question *
Very
Satisfied
5
4
3
2
Very
Dissatisfied
1
How satisfied are you with this?
155
This question requires an answer.
5a. *
Very
Clear
5
4
3
2
Very
Unclear
1
How clear are the procedures about what to
do if something goes wrong?
This question requires an answer.
5b. Considering your answer to the last question *
Very
Satisfied
5
4
3
2
Very
Dissatisfied
1
How satisfied are you with this?
This question requires an answer.
6a. How often do you turn to the following people for support when you are experiencing
difficulty at work? *
Always
5
4
3
2
Never
1
Direct Line Manager
Colleagues
This question requires an answer.
6b. In response to your answers to the last question, how satisfied are you with this? *
Very
Satisfied
5
4
3
2
Very
Dissatisfied
1
Direct Line Manager
Colleagues
This question requires an answer.
7. Finally, please respond to the following statements: *
Strongly
Agree
Agree
Undecided
Disagree
Strongly
Disagree
156
I am satisfied with my present situation at
work
I feel I belong to a valued staff group
I am satisfied with my present level of
involvement in decision making at work
I often think about finding another job
Overall, I am satisfied with the degree of
support I receive in my job
Harris, P., & Rose, J. (2002). Measuring staff support in services for people with intellectual disability: The Staff Support and Satisfaction Questionnaire, Version 2. Journal for Intellectual Disability Research, 46, 151 - 157.
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
62%
Social support questionnaire shortened version (Sarason, Sarason, Shearin, & Pierce, 1987)
This question requires an answer.
The following questions ask about people in your environment who provide you with
help or support.
Each question has two parts:
For the first part, select from the drop down menu the number of people you
know excluding yourself, who you can count on for help or support in the
manner described. Select from the range 'No One' to '9 people'.
For the second part, select from the drop down menu how satisfied you are
with the overall support you have. Select from the range 'Very Satisfied' to
'Very Dissatisfied'.
If you have no support for a question, select the words 'No one,' but still rate your
level of satisfaction.
Please answer all the questions as best you can.
*
157
Number of people you can
count on for support
(No One to 9 people)
How satisfied are you
with the overall support
you have?
(Very Satisfied to Very
Dissatisfied)
Who can you really count on to be
dependable when you need help?
Who can you really count on to help
you feel more relaxed when you are
under pressure or tense?
Who accepts you totally, including
your worst and your best points?
Who can you really count on to care
about you, regardless of what is
happening to you?
Who can you really count on to help
you feel better when you are feeling
generally down-in-the-dumps?
Who can you count on to console
you when you are very upset?
Sarason, I. G., Sarason, B. R., Shearin, E. N., & Pierce, G. R. (1987). A brief measure of social support: Practical and theoretical implications. Journal of Social and Personal Relationships, 4, 497-510.
The Maslach Burnout Inventory is copyrighted therefore only three items of the measure
can be reproduced.
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
69%
Maslach Burnout Inventory - Human Services Survey (Christina Maslach & Susan E. Jackson) The purpose of this survey is to discover how various persons in the human services, or helping professionals view their job and the people with whom they work closely. Because persons in a wide variety of occupations will answer this survey, it uses the term recipients to refer to the people for whom you provide
158
your service, care, treatment, or instruction. When answering this survey please think of the adults with learning disabilities and challenging behaviour that you support as recipients of the service you provide. This question requires an answer.
Here are 22 statements of job-related feelings. Please read each statement carefully
and decide if you ever feel this way about your job. If you have never had this feeling,
tick the box for number '0' (zero). If you have had this feeling indicate how often you
feel it by ticking the box associated with the number (from 1 to 6) and statement that
best describes how frequently you feel that way. *
Never
0
A few
times a
year or
less
1
Once a
month
or less
2
A few
times a
month
3
Once a
week
4
A few
times a
week
5
Every
day
6
I feel emotionally drained from my
work
I feel used up at the end of the
workday
I feel fatigued when I get up in the
morning and have to face another
day on the job
MBI-Human Services Survey: Copyright © 1981 Christina Maslach & Susan E. Jackson All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
75%
The Positive Affect and Negative Affect Scale (Watson, Clark, & Tellegen, 1988) This question requires an answer.
This scale consists of a number of words that describe different feelings and emotions.
Read each item and then tick the appropriate answer. Indicate to what extent you
have felt this during the past week from '1 = Very slightly or not at all' to '5 =
Extremely' by ticking one of the boxes.
*
Very slightly
or
A Little
Moderately
Quite a Bit
Extremely
159
not at all
1
2 3 4 5
Interested
Distressed
Excited
Upset
Strong
Guilty
Scared
Hostile
Enthusiastic
Proud
Irritable
Alert
Ashamed
Inspired
Nervous
Determined
Attentive
Jittery
Active
Afraid
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS Scales. Journal of Personality and Social Psychology, 54, 1063-1070.
160
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
81%
Confirmation that you wish your answers to the questionnaires to be submitted This question requires an answer.
You have now completed all the questionnaires.
Please select the appropriate response from the two options below:
*
I am happy to submit my answers to the questionnaires and participate in this research
study
I do not wish to submit my answers to the questionnaires and wish to withdraw from
this research study
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
88%
Thank you for completing this survey. If you have any questions about the survey you have just completed or the research study please contact the primary researcher Nicola Brame at the email address [email protected] or telephone 07581 065743. If you have any further questions you can contact the research supervisor Prof David Peck at the email address [email protected] A summary of the results of this survey will be available to view at the webpage address http://tinyurl.com/NBresults when this study is completed in June 2014. Please make a record of this webpage address and access it after June 2014 if you would like to read the results of this research study. If you have found completing this survey distressing please contact the researcher Nicola Brame on 07581 065743 or [email protected] If you are feeling stressed, anxious, depressed, overwhelmed or finding it difficult to cope please contact your GP or NHS Direct on the telephone numbers 111 or 0845 4647, or visit http://www.nhsdirect.nhs.uk For immediate and confidential emotional support contact the Samaritans on 08457 90
161
90 90 or http://www.samaritans.org/ Your local Wellbeing or Improving Access to Psychological Therapies (IAPT) service can offer support to make changes in your life to manage levels of stress as well as symptoms of anxiety and depression. To find your local service and information about managing stress or making a self-referral visit the website http://www.iapt.nhs.uk/services/ or if you live within Norfolk and Suffolk go to https://www.readytochange.org.uk/Pages/Home.aspx For information about common mental health problems the service MIND can be contacted on 0300 123 3393 or http://www.mind.org.uk
Investigating the wellbeing of staff working with adults with learning disabilities and challenging behaviour
94%
Prize Draw
Please complete these details ONLY if you would like to enter into the prize draw for the
chance to win one of two Love2shop gift vouchers worth £50 each and redeemable at High
Street shops Argos, Debenhams, Wilkinsons, Boots, Toys R Us, New Look, River Island,
Show Zone, HMV, H.Samuel, Homebase, and Mothercare, as well as restaurants and
leisure attractions.
All information provided here will be kept confidential and will be destroyed once the
survey closes and two winners have been selected in the prize draw and received their
vouchers. The survey will close when 77 participants have been recruited.
If you are selected as a winner you will be emailed shortly after the survey has closed and
asked to provide an address to post the voucher to. You will be posted the voucher and
asked to sign a receipt to state that you have received the voucher. You will be asked to
return this receipt to the researcher in the stamped addressed envelope provided. The two
receipts will be used as evidence that the prize draw took place and that two winners
received their vouchers.
Please make sure the email address you provide is correct and that you check your account
regularly. If you are emailed to say you have won and we do not receive a response within
three weeks another winner will be chosen at random.
Name
Address
This question requires an answer.
162
You do not have to participate in the prize draw if you do not want to provide your
personal details.
Please select the appropriate option:
*
I do not wish to participate in the prize draw and would like to exit the survey.
I have entered my personal details and would now like to exit the survey.
Thank you for your interest in this research study. If you have found completing this survey distressing please contact the researcher Nicola Brame on 07581 065743 or [email protected] If you are feeling stressed, anxious, depressed, overwhelmed or finding it difficult to cope please contact your GP or NHS Direct on the telephone numbers 111 or 0845 4647, or visit http://www.nhsdirect.nhs.uk For immediate and confidential emotional support contact the Samaritans on 08457 90 90 90 or http://www.samaritans.org/ Your local Wellbeing or Improving Access to Psychological Therapies (IAPT) service can offer support to make changes in your life to manage levels of stress as well as symptoms of anxiety and depression. To find your local service and information about managing stress or making a self-referral visit the website http://www.iapt.nhs.uk/services/ or if you live within Norfolk and Suffolk go to https://www.readytochange.org.uk/Pages/Home.aspx For information about common mental health problems the service MIND can be contacted on 0300 123 3393 or http://www.mind.org.uk
163
For use by Nicola Brame only. Received from Mind Garden, Inc. on June 3, 2013
www.mindgarden.com
To whom it may concern, This letter is to grant permission for the above named person to use the following copyright material for his/her thesis or dissertation research: Instrument: Maslach Burnout Inventory, Forms: General Survey, Human Services Survey & Educators Survey
Copyrights: MBI-General Survey (MBI-GS): Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI-Human Services Survey (MBI-HSS): Copyright ©1981 Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI-Educators Survey (MBI-ES): Copyright ©1986 Christina Maslach, Susan E. Jackson & Richard L. Schwab. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com Three sample items from a single form of this instrument may be reproduced for inclusion in a proposal, thesis, or dissertation. The entire instrument may not be included or reproduced at any time in any published material. Sincerely,
Robert Most Mind Garden, Inc. www.mindgarden.com MBI-General Survey: Copyright ©1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. MBI-Human Services Survey: Copyright ©1981 Christina Maslach & Susan E. Jackson. MBI-Educators Survey: Copyright ©1986 Christina Maslach, Susan E. Jackson & Richard L. Schwab. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com
Appendix E
Permission from Mind Garden to use the Maslach Burnout Inventory in the online
study.
164
Appendix F
University of East Anglia Faculty of Medicine and Health Sciences Ethics Committee
Approval Letters
165
166
Appendix G
Box plots and histograms of the main study variables
1. Stressors
1.1. Intellectual Disability
167
1.2. Challenging behaviour.
168
1.3. Occupational demands.
169
2. Resources
2.1. Coping mechanism ‘practical coping’.
170
2.2. Coping mechanism ‘wishful thinking’.
171
2.3. Organisational support.
172
2.4. Social Support ‘number’.
173
2.5. Social support ‘satisfaction’
174
3. Appraisals
3.1. Emotional exhaustion.
175
3.2. Personal accomplishment.
176
4. Outcomes.
4.1. Positive Affect.
177
4.2. Negative Affect.
178
Appendix H
Box plot, scatter graphs and SPSS output for the main results.
Hypothesis 1. Intellectual disability group and emotional exhaustion.
179
Hypothesis 2. Challenging behaviour and emotional exhaustion.
180
Hypothesis 3. Organisational demands and emotional exhaustion.
Correlations
Staff
Stressor
Total
Emotional
Exhaustion
Total
Spearman's
rho
Staff Stressor Total Correlation Coefficient 1.000 .690**
Sig. (2-tailed) . .000
N 47 47
Bootstra
pa
Bias .000 -.012
Std. Error .000 .082
95% Confidence
Interval
Lower 1.000 .502
Upper 1.000 .818
Emotional
Exhaustion
Total
Correlation Coefficient .690** 1.000
Sig. (2-tailed) .000 .
N 47 47
Bootstra
pa
Bias -.012 .000
Std. Error .082 .000
95% Confidence
Interval
Lower .502 1.000
Upper .818 1.000
**. Correlation is significant at the 0.01 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
181
Hypothesis 4. Practical coping and personal accomplishment.
Correlations
Practical
Coping Total
Personal
Accomplish-
ment Total
Practical Coping Total Pearson Correlation 1 .021
Sig. (2-tailed) .889
N 47 47
Bootstrapa Bias 0 -.003
Std. Error 0 .151
95% Confidence
Interval
Lower 1 -.276
Upper 1 .303
Personal
Accomplishment Total
Pearson Correlation .021 1
Sig. (2-tailed) .889
N 47 47
Bootstrapa Bias -.003 0
Std. Error .151 0
95% Confidence
Interval
Lower -.276 1
Upper .303 1
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
182
Hypothesis 5. Wishful thinking and emotional exhaustion.
Correlations
Wishful
Thinking
total
Emotional
Exhaustion
Total
Spearman's
rho
Wishful thinking
total
Correlation Coefficient 1.000 .677**
Sig. (2-tailed) . .000
N 47 47
Bootstra
pa
Bias .000 -.011
Std. Error .000 .100
95% Confidence
Interval
Lower 1.000 .426
Upper 1.000 .831
Emotiona
lExhaustion Total
Correlation Coefficient .677** 1.000
Sig. (2-tailed) .000 .
N 47 47
Bootstra
pa
Bias -.011 .000
Std. Error .100 .000
95% Confidence
Interval
Lower .426 1.000
Upper .831 1.000
**. Correlation is significant at the 0.01 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
183
Hypothesis 6. Occupational support and emotional exhaustion.
Correlations
Staff
Support
Satisfaction
Total
Emotional
Exhaustion
Total
Spearman's
rho
Staff Support
SatisfactionTotal
Correlation Coefficient 1.000 -.505**
Sig. (2-tailed) . .000
N 47 47
Bootstrap
a
Bias .000 .002
Std. Error .000 .130
95% Confidence
Interval
Lower 1.000 -.723
Upper 1.000 -.210
Emotiona
lExhaustion Total
Correlation Coefficient -.505** 1.000
Sig. (2-tailed) .000 .
N 47 47
Bootstrap
a
Bias .002 .000
Std. Error .130 .000
95% Confidence
Interval
Lower -.723 1.000
Upper -.210 1.000
**. Correlation is significant at the 0.01 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
184
Hypothesis 7. Social support and personal accomplishment.
Correlations
Social
Number
Personal
Accomplish-
ment Total
Social Number Pearson Correlation 1 .335*
Sig. (2-tailed) .021
N 47 47
Bootstrapa Bias 0 .002
Std. Error 0 .128
95% Confidence
Interval
Lower 1 .065
Upper 1 .556
Personal
Accomplishment Total
Pearson Correlation .335* 1
Sig. (2-tailed) .021
N 47 47
Bootstrapa Bias .002 0
Std. Error .128 0
95% Confidence
Interval
Lower .065 1
Upper .556 1
*. Correlation is significant at the 0.05 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
185
Hypothesis 8. Personal accomplishment and positive affect.
Correlations
Personal
Accomplish-
ment Total
Positive
Feelings
Personal
Accomplishment Total
Pearson Correlation 1 .628**
Sig. (2-tailed) .000
N 47 47
Bootstrapa Bias 0 -.012
Std. Error 0 .099
95% Confidence
Interval
Lower 1 .401
Upper 1 .780
Positive Feelings Pearson Correlation .628** 1
Sig. (2-tailed) .000
N 47 47
Bootstrapa Bias -.012 0
Std. Error .099 0
95% Confidence
Interval
Lower .401 1
Upper .780 1
**. Correlation is significant at the 0.01 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
186
Hypothesis 9. Emotional exhaustion and negative affect.
Correlations
Emotional
Exhaustion
Total
Negative
Feelings
Spearman's
rho
Emotional
Exhaustion Total
Correlation Coefficient 1.000 .648**
Sig. (2-tailed) . .000
N 47 47
Bootstra
pa
Bias .000 -.007
Std. Error .000 .098
95% Confidence
Interval
Lower 1.000 .433
Upper 1.000 .806
Negative Feelings Correlation Coefficient .648** 1.000
Sig. (2-tailed) .000 .
N 47 47
Bootstra
pa
Bias -.007 .000
Std. Error .098 .000
95% Confidence
Interval
Lower .433 1.000
Upper .806 1.000
**. Correlation is significant at the 0.01 level (2-tailed).
a. Unless otherwise noted, bootstrap results are based on 1000 bootstrap samples
187
Appendix I
Timeline of recruitment
10.06.13 Organisation A: Telephone 1, email 1 to training manager
Organisation B: Telephone 1, email 1 to head of residential services
Organisation C: Telephone 1, told do not take part in research
04.07.13 Organisation D: Telephone 1 with area manager, email 1 sent with information about study
Organisation B: Email 2 to head of residential services
Organisation A: Telephone 2 to training manager, arrange meeting 12.07.13
11.07.13 Organisation B: Email 2 from director of residential services, passing on information to
medical director
Organisation B: Email 3 from medical director, telephone 1 to arrange meeting 18.07.13
12.07.13 Organisation A: Meeting 1 with training manager, permission given in principle further to
discussion with operations manager
Organisation E: Email 1 to find out appropriate person to contact
Organisation F: Email 1 to head of adult services with study information
16.07.13 Organisation D: Email 2 to area manager, Email 3 received stating information passed on
to psychology team and other area managers
Organisation D: Email 4 from regional director, telephone call arranged 18.07.13
18.07.13 Organisation D: Telephone 2 to regional director, no answer, email 5 sent requesting
telephone call
Organisation B: Meeting with medical director, permission given in principle suggests
liaison with head of therapy
19.07.13 Organisation D: Email 6 from regional director, telephone call 3 arranged 22.07.13
Organisation F: Email 2 arrange meeting to discuss research
22.07.13 Organisation D: Telephone 3 with regional director, interested in participating, will email
psychology team to gain permission
Organisation B: Email 4 to head of therapy
25.07.13 Organisation F: Meeting 1 with regional manager, permission given in principle and
provided with study advertising posters, written confirmation sent via email
05.08.13 Organisation D: Email 7 to regional director
09.08.13 Organisation A: Email 2 to training manager
Organisation E: Email 1 to head of quality
15.08.13 Organisation E: Email 2 response from head of quality, telephone 1 arranged for 19.08.13
19.08.13 Organisation E: Telephone 1 with head of quality, no contact leave message
27.08.13 Organisation A: Email 3 to training manager
Organisation D: Email 8 to regional director
Organisation D: Email 9 to area manager
Organisation E: Email 3 head of quality
Organisation A: Email 4, withdraw interest due to difficult situation within organisation,
requests contact later in the year
Organisation B: Email 5, telephone 2 with head of therapy
28.08.13 Organisation D: Email 10 from regional director, has run study past senior team and
manager, interest in participating, request next steps
29.08.13 Organisation D: Email 11 to regional director requesting gatekeeper written permission in
order to proceed
12.09.13 Organisation E: Telephone 2 head of quality, no contact
17.09.13 Organisation D: Email 12 to area manager
Organisation D: Email 13 to regional manager
Organisation E: Email 4 to head of quality, received email 5 response, arrange telephone 3
24.09.13
19.09.13 Organisation B: Email 5, telephone 3 to head of therapy
Organisation B: Telephone 4 from head of therapy, interest shown, email 6 with
information about the study.
188
21.10.13 Organisation B: Meeting 2 with director of residential services, interest in participating,
will discuss recruitment with service managers
24.10.13 Organisation E: Email 6 from head of quality
30.10.13 Organisation E: Email 7 to head of quality
31.10.13 Organisation D: Email 14 to regional director
03.11.13 Organisation G: Email 1 with information about study
04.11.13 Internet Forum 1: Posted information about the study to learning disabilities (LD forum)
professionals requesting services who might be interested in taking part to contact me.
Organisation E: Telephone 3 to head of quality, no contact
Organisation H: Telephone 1 service manager, email 1 sent with study information to be
passed on to the human resource department
Organisation D: Telephone 4 to area manager, waiting for psychology department to get
back to her, email 15 sent requesting psychology department contact details.
Person A: Email 1 in response to LD forum advertisement, providing written permission to
advertise through their service, emailed 2 recruitment poster
06.11.13 Person B: Email 1 in response to LD forum advertisement, email 2 sent with information
to pass on to Learning disability home managers
Clinical psychologist 1: Email 1 requesting advice about local service providers to contact
about my research, email forwarded on to learning disabilities nurse.
15.11.13 Clinical psychologist 2: Email received in response to LD forum advertisement, emailed
information about study to forward on to colleagues
18.11.13 Organisation G: Email 2 received, interest in taking part, email 3 response with further
information
Organisation E: Telephone 4 head of quality, no contact
19.11.13 Organisation G: Email 3 written permission received to recruit through services
Learning disability nurse: Email 2 response from local learning disabilities nurse with
information about local services to contact
25.11.13 Organisation E: Telephone 5 with head of quality, asks me to email behavioural specialist
to continue discussions, email 8 sent
26.11.13 Organisation D: Telephone 5 to regional manager, waiting for permission, asks me to
follow up directly with psychologist
28.11.13 Attend Learning Disability Today Conference in London, speak to organisations that meet
study criteria with information stalls:
- Organisation H: talk with director of operations and provide information about study,
given email contact to follow-up
- Organisation I: talk with and provide information, given email contact to follow-up
- Organisation J: talk with, given email contact to pass on information
- Organisation K: talk with, conduct internal research only
- Organisation L: talk with, currently conducting other research project, not interested at
the moment
- Organisation M: speak with, currently in period of transition, may be interested in future
02.12.13 Organisation H: Email 1, follow up conversation
Organisation D: Telephone 6 with psychologist, interested in taking part, email 16 sent
with information about the study and letter of ethical approval
03.12.13 Organisation I: Email 1, following up conversation
04.12.13 Organisation J: Email 1 with information about the study
Organisation B: Email 7 to director of residential services
Organisation E: Email 9 to behavioural therapist
Organisation A: Email 5 to training manager, explore timing being better
05.12.13 Organisation B: Email 8 from director of residential services, permission given to
telephone residential services and arrange meetings or post advertising poster and
recruitment letters
06.12.13 Organisation A: Email 6 from training manager, will discuss study with operations
manager
10.12.13 Organisation A: Email 7 to training manager.
189
11.12.13 Organisation G: Email 4, received ethical approval, email recruitment letter and survey
link to be distributed to staff.
Organisation N: Email 1 clinical psychologist with initial study information
Organisation B: Telephone 5-7 with three services, arrange to post 45 recruitment letters
and study posters to two services
12.12.13 Organisation B: Telephone 8 with service, arrange to post 20 recruitment letters and study
posters
13.12.13 Organisation A: Email 6 from training manager, interested in study, arrange meeting on
06.01.13
Organisation N: Email 2 from clinical psychologist, will pass on information to clinical
director
16.12.13 Organisation N: Email 3 from clinical psychologist with permission from director to
recruit, email 4 requesting advice on how to proceed.
Organisation B: Telephone 9 with service, arrange to send 35 recruitment letters and study
posters
06.01.14 Organisation A: Meeting 2 with training manager and head of operations, interested in
participating, provide 100 recruitment letters and advertising posters, request written
permission to be emailed
07.01.14 Organisation B: Telephone 10-12 with three services, arrange to send 20 recruitment
letters, arrange to attend staff meeting on 29.01.14
08.01.14 Organisation E: Email 10 to behavioural therapist
Organisation D: Email 17 to psychologist
16.01.14 Organisation N: Email 5 to clinical psychologist, email 6 response stating I can proceed by
contacting service managers directly
20.01.14 Organisation O: Telephone 1 with training co-ordinator, email 1 with study information to
pass on to service manager.
22.01.14 Organisation N: Telephone 1-3 with service managers, arrange to attend two staff
meetings and to email information about the study to the third to be distributed amongst
staff
27.01.14 Organisation H: Email 2 to director of operations.
Organisation I: Email 2 follow-up
Organisation J: Email 2 follow-up
Organisation F: Email 3 requesting permission to recruit through services in different area
27.01.14 Organisation P: Email 1 with initial study information
Organisation Q: Email 1 with initial study information
Organisation R: Email 1 with initial study information
29.01.14 Organisation B: Telephone 13 to service, arrange to post 35 recruitment letters.
Organisation B: Meeting with staff team within a service
05.02.14 Organisation N: Meeting 1 with staff team within a service
Organisation F: Email 4 to head of adult services
09.02.14 Organisation R: Email 2 received from organisation manager, permission to proceed,
email 3 with next steps
12.02.14 Organisation O: Meeting 1 with training co-ordinator, provide 50 recruitment letters,
request email written permission
Organisation N: Meeting 2 with staff team within service
17.02.14 Organisation F: Telephone 1 with head of residential services, permission to recruit
through further services, email 5 with link to study to be forwarded on.
Organisation P: Telephone 1, email 1 sent to service manager with study information
Organisation Q: Telephone 1, email 1 with study information to be forwarded on to area
manager.
18.02.14 Internet forum 2-4: Request permission and post study advertisement
19.02.14 Organisation F: Telephone 2-3 with service managers, arrange to post 70 recruitment
letters to be distributed to staff
Person C: Receive message in response to internet advertisement, email study information
to be forwarded on to learning disability services
190
Person D: Receive message in response to internet advertisement, forward on information
about study to be passed on to service manager
20.02.14 Person E: Receive message in response to internet advertisement, forward on information
about study to be passed on to service manager
24.02.14 Person F: Receive message in response to internet advertisement, forward on information
about study to be passed on to colleagues in learning disability services
26.02.14 Organisation A: Email 7 to training manager, follow-up, request written permission
Organisation D: Telephone 7, email 18 psychologist, email 19 response re-requesting
information to be forwarded on to organisation CEO
Person G: Receive message in response to internet advertisement, forward on information
about study to be passed on to colleagues in two learning disability services
Person H: Received message in response to internet advertisement, forward on information
about study to be passed on to colleagues in learning disability services
05.03.14 Organisation S: Email 1 with initial study information.
09.03.14 Organisation S: Email 2 received, interest in participating, will pass on information to
service manager, email 3 with further study information
12.03.14 Organisation T: Completion of online form requesting permission to advertise study
through online forum
Organisation U: Completion of online form requesting information about the appropriate
person to contact to discuss study
Organisation R: Email 3 requesting 30 recruitment letters to be posted and distributed to
staff
30.03.14 Internet forum 5 -6: Post study advertisement
Organisation V: Completion of online form requesting advertisement of study through
online forum
Organisation W: Email 1, follow up to service identified by Person G
Organisation X: Email 1, follow up to service identified by Person G
01.04.14 Organisation D: Email 20 to psychologist, email 21 response stating they are in discussion
with CEO
09.04.14 Organisation D: Email 22 received from psychologist with written permission to recruit
through their services
Email 23 to regional director, email 24 reply stating they will email out a brief summary of the
research, the survey link and recruitment letter to their service managers
Telephone 8 to area manager, no contact, email 24
15.04.14 Organisation D: Email 25 confirmation from regional director that they have emailed all
the service management team in their region, to be forwarded on to their staff.
22.04.14 Organisation D: Telephone 9 to area manager, no contact, email 25
30.04.14 Close survey.